Housing First

Housing First programs address chronic homelessness by providing rapid access to permanent housing, without a pre-condition of treatment, along with ongoing support services such as crisis intervention, needs assessment, and case management. A form of permanent supportive housing, the program usually serves individuals who are chronically homeless and have persistent mental illness or problems with substance abuse and addiction. Clients can be placed in apartments throughout a community (Stergiopoulos 2012) or a centralized housing location with on-site support for those requiring more intensive services; clients receive housing regardless of substance use (Patterson 2013). Unlike standard rapid re-housing programs, there are no time limits for Housing First program participation (Urban-Cunningham 2015). 

Expected Beneficial Outcomes (Rated)

  • Reduced homelessness

  • Increased housing stability

  • Reduced hospital utilization

Other Potential Beneficial Outcomes

  • Improved mental health

  • Improved well-being

  • Increased substance use disorder treatment

Evidence of Effectiveness

There is strong evidence that Housing First programs reduce homelessness (, Palepu 2013, Gulcur 2003, ), increase housing stability (, , , , Palepu 2013, , ), and reduce hospital utilization  (Cochrane-Stergiopoulos 2015, Fitzpatrick-Lewis 2011, , ).

Housing First programs improve housing stability for people with mental disorders (, Palepu 2013, ), including homeless youth (), particularly when programs include strong case management (). Programs can also increase housing stability for veterans (), chronically homeless individuals (), and survivors of domestic violence and their families (Mbilinyi 2015). Housing First programs reduce hospital utilization among veterans () and individuals with persistent mental illness or problems with substance abuse and addiction (Cochrane-Stergiopoulos 2015, Fitzpatrick-Lewis 2011, ), and decrease utilization of psychiatric hospitals for formerly homeless individuals with mental illness (Gulcur 2003).

Housing First programs can improve mental health and well-being for participants (, ), and may also increase treatment for substance abuse and addiction (, ). Programs with strong case management components can improve participants’ functioning in the community (Cochrane-Stergiopoulos 2015). Program participants report significantly higher quality of life than non-participants, as well as greater safety and comfort in their new dwellings (Patterson 2013).

An Alaska-based study of a Housing First program for chronically homeless individuals indicates such programs can reduce homelessness, improve physical and mental health, and increase social engagement among participants (). Programs for domestic violence survivors and their families appear to increase housing stability, safety, and well-being; participants often do not require substantial financial assistance at program completion (Mbilinyi 2015).

Housing First programs may reduce substance misuse and severe alcohol problems (, ); however, in some instances substance use-related outcomes do not differ significantly between participants and non-participants (). Additional evidence is needed to confirm the effects of program participation on substance abuse ().

Strong partnerships between Housing First program staff and landlord associations can support gains in housing stability. Connecting program staff with clients of the same ethnic or racial background often results in the most successful working relationships (Stergiopoulos 2012). Using video calling to connect program participants and staff can increase program reach (). Programs which encourage community integration and supportive social networks can contribute to long-term housing stability ().

Housing First programs decrease costs to shelters (, Ly 2015) and emergency departments (Ly 2015). The rapid re-housing component of Housing First can reduce costs associated with hospitalizations and treatment for individuals with persistent mental illness and substance abuse problems (, Urban-Cunningham 2009). Early studies suggest Housing First programs generally also cost less than programs that require sobriety or treatment prior to providing housing (Gulcur 2003).

Impact on Disparities

Likely to decrease disparities

Implementation Examples

Housing First programs have been implemented in more than 100 cities across the United States, Canada, Europe, and Australia (Pathways HF). Pathways to Housing, the New York-based organization from which Housing First originated, trains organizations to follow the Housing First model; Pathways to Housing agencies include Pathways Washington DC and Pathways Pennsylvania (Pathways HF, Pathways HF-DC, Pathways HF-PA).

The Washington State Coalition Against Domestic Violence’s Domestic Violence Housing First program is an example of an organization that focuses on survivors of domestic violence and their families (WSCADV-Housing First toolkit).

There are many veteran-specific programs which use Housing First principles. The HUD-VA Supported Housing (HUD-VASH) program, a supportive housing program for homeless veterans with psychiatric or substance abuse disorders, includes rental assistance vouchers from the US Department of Housing and Urban Development (US HUD) combined with case management and clinical services provided by the US Department of Veteran Affairs (VA); 93,000 vouchers have been awarded and approximately 150,000 homeless veterans have been served by HUD-VASH since 2008 (HUD-VASH, HUD-VASH 2018). The Mayors Challenge to End Veteran Homelessness, an additional partnership between the VA and US HUD, uses concepts from Housing First, rapid re-housing, and permanent supportive housing with added mental health services (US ICH-Veteran homelessness). The Built for Zero Collaborative, a national movement to end chronic and veteran homelessness, also uses Housing First principles; 96,000 people have gained housing in participating communities since January 2015, including 65,000 veterans (Built for Zero).

Implementation Resources

NAEH-Housing First - National Alliance to End Homelessness (NAEH). Housing First: Includes checklist to implement program, how to use models, and special reports.

US ICH-Housing First - United States Interagency Council on Homelessness (US ICH). Housing First: Featured tools to implement Housing First program.

MHCC-Housing First - Mental Health Commission of Canada (MHCC). Canadian Housing First Toolkit: Developed to assist other Canadian communities who are interested in adopting the Housing First approach.

Built for Zero - Community Solutions. Built for Zero: a national change effort to end veteran and chronic homelessness.

Pathways HF - Pathways Housing First. Training and consulting for the Housing First model.

Safe Housing Partnerships - Safe Housing Partnerships. Rapid re-housing, housing first, housing tax credits, and other affordable housing approaches. Domestic Violence and Housing Technical Assistance Consortium: a collaboration of the Administration for Children and Families, US Department of Health and Human Services; the Office on Violence Against Women and the Office for Victims of Crime, US Department of Justice; and the Office of Special Needs Assistance Programs, US Department of Housing and Urban Development.

Homeless Hub-HF - Homeless Hub. Accommodations and supports: Housing First (HF). Canadian Observatory on Homelessness.

Citations - Evidence

* Journal subscription may be required for access.

Gulcur 2003* - Gulcur L, Stefancic A, Shinn M, Tsemberis S, Fischer SN. Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in continuum of care and housing first programmes. Journal of Community and Applied Social Psychology. 2003;13(2):171-86.

Nelson 2007* - Nelson G, Aubry T, Lafrance A. 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 Orthopsychiarty. 2007;77(3):350-61.

Fitzpatrick-Lewis 2011 - Fitzpatrick-Lewis D, Ganann R, Krishnaratne S, et al. Effectiveness of interventions to improve the health and housing status of homeless people: A rapid systematic review. BMC Public Health. 2011;11:638.

Tsemberis 2012* - Tsemberis S, Kent D, Respress C. Housing stability and recovery among chronically homeless persons with co-occurring disorders in Washington, DC. American Journal of Public Health. 2012;102(1):13-6.

Urban-Cunningham 2009 - Cunningham M. Preventing and ending homelessness - Next steps. Metropolitan Housing and Communities Center. Washington, DC: Urban Institute; 2009.

Kirst 2015* - Kirst M, Zerger S, Misir V, Hwang S, Stergiopoulos V. The impact of a Housing First randomized controlled trial on substance use problems among homeless individuals with mental illness. Drug and Alcohol Dependence. 2015;5(1):24-29.

Stergiopoulos 2012 - Stergiopoulos V, O'Campo P, Gozdzik A, et al. Moving from rhetoric to reality: Adapting Housing First for homeless individuals with mental illness from ethno-racial groups. BMC Health Services Research. 2012;12:345.

Palepu 2013 - Palepu A, Patterson ML, Moniruzzaman A, Frankish CJ, Somers J. Housing First improves residential stability in homeless adults with concurrent substance dependence and mental disorders. American Journal of Public Health. 2013;103(2)e30-e36.

Patterson 2013 - Patterson M, Moniruzzaman A, Palepu A, et al. Housing First improves subjective quality of life among homeless adults with mental illness: 12-month findings from a randomized controlled trial in Vancouver, British Columbia. Social Psychiatry and Psychiatric Epidemiology. 2013;48(8):1245-1259.

Cochrane-Stergiopoulos 2015 - Stergiopoulos V, Gozdzik A, Misir V, et al. Effectiveness of Housing First with intensive care management in an ethnically diverse sample of homeless adults with mental illness: A randomized controlled trial. PLOS One. 2015;10(7):e0130281.

Somers 2015* - Somers JM, Moniruzzaman A, Palepu A. Changes in daily substance use among people experiencing homelessness and mental illness: 24-month outcomes following randomization to Housing First or usual care. Addiction. 2015;110(10):1605-1614.

Stefancic 2013* - Stefancic A, Henwood BF, Shin SM, et al. Implementing Housing First in rural areas: Pathways Vermont. American Journal of Public Health. 2013;103(S2):S206-S209.

Srebnik 2013* - Srebnik D, Connor T, Sylla L. A pilot study of the impact of Housing First- Supported housing for intensive users of medical hospitalization and sobering services. American Journal of Public Health. 2013;103(2):316-321.

Montgomery 2013* - Montgomery AE, Hill LL, Kane V, Culhane DP. Housing chronically homeless veterans: Evaluating the efficacy of a Housing First approach to HUD-VASH. Journal of Community Psychology. 2013;41(4):505-514.

Stergiopoulos 2015* - Stergiopoulos V, Hwang SW, Gozdzik A, et al. Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: a randomized trial. Journal of the American Medical Association. 2015;313(9):905-915.

Ly 2015 - Ly A, Latimer E. Housing First impact on costs and associated cost offsets: A review of the literature. Canadian Journal of Psychiatry. 2015;60(11):475-487.

Tsemberis 2000* - Tsemberis S, Eisenberg RF. Pathways to housing: supported housing for street-dwelling homeless individuals with psychiatric disabilities. Psychiatric services. 2000;51(4):487-493.

Gulcur 2003 - Gulcur L, Stefancic A, Shinn M, Tsemberis S, Fischer SN. Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities. Journal of Community and Applied Social Psychology. 2003;13:171-186.

Campbell-Munthe-Kaas 2018* - Munthe-Kaas HM, Berg RC, Blaasvaer N. Effectiveness of interventions to reduce homelessness: A systematic review and meta-analysis. Campbell Systematic Reviews. 2018:1-284.

Mbilinyi 2015 - Mbilinyi L. The Washington State Domestic Violence Housing First Program: Cohort 2 agencies final evaluation report, September 2011 – September 2014. Washington State Coalition Against Domestic Violence. The Bill & Melinda Gates Foundation; 2015.

Boland 2018a* - Boland L, Slade A, Yarwood R, Bannigan K. Determinants of tenancy sustainment following homelessness: A systematic review. American Journal of Public Health. 2018;108(11):e1-e8

Kozloff 2016* - Kozloff N, Adair CE, Palma Lazgare Li, et al. “Housing First” for homeless youth with mental illness. Pediatrics. 2016;138(4):1-12.

Driscoll 2018* - Driscoll DL, Johnston JM, Chapman C, et al. Changes in the health status of newly housed chronically homeless: the Alaska Housing First program evaluation. Journal of Social Distress and the Homeless. 2018;27(1):34-43.

Citations - Implementation Examples

* Journal subscription may be required for access.

US ICH-Veteran homelessness - United States Interagency Council on Homelessness (US ICH). Mayors challenge to end veteran homelessness: Criteria and benchmarks for ending veteran homelessness.

Built for Zero - Community Solutions. Built for Zero: a national change effort to end veteran and chronic homelessness.

Pathways HF - Pathways Housing First. Training and consulting for the Housing First model.

Pathways HF-DC - Pathways to Housing DC. Housing First (HF) program. Washington, DC.

Pathways HF-PA - Pathways to Housing PA. Housing First (HF) program. Pennsylvania.

HUD-VASH - US Department of Housing and Urban Development (US HUD). Veterans Affairs Supportive Housing (VASH): HUD-VASH Vouchers.

HUD-VASH 2018 - US Department of Housing and Urban Development (US HUD). HUD and VA announce additional support to help homeless veterans find permanent homes: Second round of HUD-VASH vouchers to provide housing for veterans and their families. HUD Public Affairs, press release; December 11, 2018.

WSCADV-Housing First toolkit - Washington State Coalition Against Domestic Violence (WSCADV). Domestic violence Housing First toolkit.

Date Last Updated

Mar 7, 2019