There is strong evidence for supportive housing's impact on social outcomes, particularly those related to housing stability and the reduction of homelessness, and sufficient evidence for its impact on reducing healthcare utilization.
The findings below summarize the results of studies on the effectiveness of supportive housing for stabilizing people experiencing homelessness and housing insecurity across three measurement domains:
There is growing consensus that access to safe and affordable housing is a key health determinant. Housing can impact health based on accessibility, affordability, stability, quality, safety, and surroundings.
Housing Stability
Affordable housing in the United States (U.S.) has become increasingly difficult to access. In 2023, 51.8% of all American renters spent at least 30% of their income on rent[1]. In 2020, one in five U.S. households reported challenges with being able to afford their rent or mortgage payment and, therefore, were identified as housing insecure[2]. Up to 3.6 million eviction cases were filed annually between 2000 and 2018 [3],[4]. Individuals are more likely to be evicted if they identify as Black or Hispanic/Latino, women, or low-income[5]. The housing affordability crisis is compounded by a steep rise in the cost of rent while the increase in renters’ earnings lag[6]. A U.S. Conference of Mayors survey found seven of 10 Americans are concerned about housing costs and its affordability[7].
In the past three years, the median monthly rental price has increased by 18% and the median purchase price for housing has increased by 21% leading to increased homelessness[8]. The U.S. Department of Housing and Urban Development (HUD) identifies “a person who lacks a fixed, regular and adequate nighttime residence” as experiencing homelessness[9]. According to the National Alliance to End Homelessness, a January 2023 count identified a record-high of 653,104 people experiencing homelessness (a 12.1% increase since 2022) across the U.S., with more than 50% of those individuals experiencing unsheltered homelessness. About 61% of people experiencing homelessness identify as men, while homelessness among those who identify as women is growing rapidly by over 20% between 2022 to 2023. Since 2015, transgender individuals have experienced a 217% increase in homelessness[10].
The two factors that pose the greatest risk for homelessness are being severely housing cost-burdened and living in “doubled-up” overcrowded homes, also known as ‘couch surfing.’ Additional risks include an individual that identifies as LGBTQ+, being a survivor of intimate partner violence, exiting the criminal justice system, being a youth aging out of foster care, as well as ongoing mental health and substance use disorders[11]. Individuals in these groups may face discrimination and safety issues that make accessing both housing and sustainable employment difficult.
Housing Quality and Impact on Health
The health effects of housing instability and homelessness include adverse physical and mental health outcomes, chronic disease, and injury. There is a significant association between eviction rates and any cause of mortality with the strongest association in counties with higher proportions of Black and women residents[12]. Black, American Indian/Alaska Native, and Hispanic/Latino communities disproportionately live in households that are rent-burdened and of low housing quality while experiencing some of the greatest health disparities[13].
Housing of poor quality can directly impact health via exposure to things like lead, mold, asbestos, or poor air quality[14]. Additionally, exposure to extreme indoor temperatures, overcrowding, or lack of proper fire safety requirements (e.g., smoke and carbon monoxide alarms) can be deleterious to health. Poor housing conditions have a disproportionately adverse impact on children, older adults, people with physical disabilities, and individuals of low socioeconomic status. Housing quality also includes neighborhood factors such as incidence of violence, environmental conditions, access to transportation, and availability of other social services and supports.
Supportive housing provides a combination of affordable housing and other services and social supports, such as health care, mental health care, and job training to provide a sustainable housing solution for individuals experiencing complex barriers to housing[15]. Typically, supportive housing has no time limit for the duration of occupancy. Many supportive housing programs are permanent supportive housing programs that take a “housing first” approach, meaning that a person should be housed before addressing potential underlying health conditions that may make obtaining stable housing more difficult (for example mental health conditions or substance use)[16].
Annually, HUD awards the Emergency Solutions Grant and the Continuum of Care (CoC) program to communities that provide localized housing support[17]. The CoC program funds supportive housing as well as other housing-related services and pilot programs. Almost 30 states have some form of Medicaid coverage for housing services[18]. The Corporation for Supportive Housing’s Medicaid Waivers Map depicts states with supportive housing strategies and provides information on those strategies. In addition to explicit housing services, Medicaid programs provide a range of mental health and substance use disorder benefits for all enrollees. States have flexibility to define these benefits, including case management, individual and group therapy, detoxification, and medication management[19].
Corporation for Supportive Housing. Available at: https://www.csh.org/.
Medically complex families with children in Boston, Massachusetts.
Permanent supportive housing (PSH) included intensive case management and wraparound services, assistance with searching for housing, eviction prevention, legal services, financial services, and a public housing unit if they were eligible. The control group families received standard of care which included a list of resources detailing housing services available in the community in addition to hospital-based social work and care navigation services.
Pilot RCT. The sample size was 67, with 36 in the intervention group and 31 in the control group. Changes from the baseline interview to the six-month interview were first examined.
Healthcare Cost, Utilization & Value: Both groups demonstrated significant reductions in their healthcare use. There were no significant differences in the number of child urgent care visits, ED visits, or hospitalizations.
Health: There were significantly greater improvements in child health status and parental anxiety and depression scores among those in the intervention group. Compared to baseline, at the six-month follow-up there was a 21.5% decrease in fair/poor child health (a decrease 32% greater than the control group), a 1.81-point decrease in mean Generalized Anxiety Disorder (GAD-2) score (compared to only a .41 decrease in the control group) and a 1.37-point decrease in Patient Health Questionnaire 2 (PHQ-2) score in the intervention group (compared to a .31 decrease in the control group).
Children who were housed at six months also had a lower prevalence of developmental risk than those who were not (0% versus 62.5%). There were no significant differences in either group for child body mass index, child developmental risk, or parent overall health.
Social: There were no significant differences in homelessness, multiple moves, being behind on rent, number of child urgent care visits, ED visits, or hospitalizations.
Chronically homeless Medicaid beneficiaries in Massachusetts.
There are two statewide Housing First (HF) PSH initiatives that serve individuals who experience chronic homelessness: Healthy for Good and the Social Innovation Financing Pay for Success program. Participants were also enrolled in the Community Support Program for People Experiencing Chronic Homelessness, a Medicaid-funded program that provides community-based support services for individuals who experience chronic homelessness.
Retrospective longitudinal matched cohort design. The analysis included the intervention group (n=690) from two years before until one year after enrollment in Housing First, and a matched comparison group (n=690) not enrolled in Housing First.
Healthcare Cost, Utilization & Value: Relative to the comparison group during the year after enrollment, Housing First enrollees on average had 33% fewer ED visits (3 vs. 4.5 per person); 31% fewer hospital admissions (1.8 vs. 2.6); 43% fewer inpatient days (7.7 vs. 13.4); 20% more mental health care visits (11.2 vs. 9.3 per person); and 27% fewer other visits (15.3 vs. 20.9). Difference of $5,267 (17%) per person per year (PPPY) in total health care costs between participants and comparison group ($25,614 vs. $30,881 PPPY) was not statistically significant.
Adult Medicaid beneficiaries in 19 of 21 New Jersey counties.
PSH programs primarily serve people with special needs, including those who experience chronic homelessness and/or have a disability. PSH residents were typically offered case management, assistance finding and maintaining housing, referrals to mental and physical health care, and referrals to social services.
Observational study with a comparison group. Difference-in-differences comparisons were made during the six months before and six months after enrollment in PSH (n=1,442) relative to a matched comparison group (n=6,064).
Healthcare Cost, Utilization & Value: Relative to the comparison group, PSH enrollees had a 14% decrease in ED visits, a 25.2% decrease in emergency department spending, a 14.6% decrease in hospital admissions, and no significant difference in primary care visits. There was no significant reduction in total Medicaid spending, largely due to increased spend on pharmaceuticals. Inpatient spending fell for the PSH group but was not statistically significant.
Elderly Medicare beneficiaries in Queens, New York.
Community-based PSH program that supplied affordable housing with supportive social services including Medicaid-funded home services, Supplemental Nutrition Assistance Program (SNAP), psychological assessments, counseling, advocacy, health education, wellness, and access to a list of local service providers (e.g., transportation, physician, pharmacy).
Observational study with a comparison group. n=1,248 in the intervention group, and 15,947 in the matched comparison group.
Healthcare Cost, Utilization & Value: Total hospital discharge rate was 32% lower for PSH vs. comparison group. The rate of hospital discharge for ambulatory care-sensitive conditions was 30% lower for PSH compared to controls (43% lower after controlling for demographic factors). The mean length of hospital stays for the PSH group (6.38 days) was one day shorter than the comparison group (a difference of 13.5%).
People in Denver, Colorado experiencing homelessness. Of the 549 individuals, 86% were men, 48% were White, and 34% were Black. Both study groups had high utilization of mental health (37%), substance use (67%), and wound care (36%) services.
A supportive housing program that integrated an HF approach. Treatment group participants were referred to one of two supportive housing providers that offered comprehensive wraparound services. The control group received services as usual in the community, which primarily included access to emergency shelters and some short-term housing assistance.
Randomized controlled trial. There were 275 participants in the treatment group and 274 in the control group for whom the study had healthcare data.
Healthcare Cost, Utilization & Value: Two-year post-randomization analysis found an increase in outpatient behavioral health care and prescription medication use (on average three or more unique prescriptions) and a decrease in ED visits (on average six fewer visits) for the treatment group. The intervention group was 5% less likely to be enrolled in Medicaid although both groups had an increase in Medicaid enrollment from the pre-randomization period. On average, the intervention group received 12 more “other services” over two years.
The share of people receiving Medicaid-billed services for any mental health diagnoses was 34% higher in the intervention group.
The intervention group was also 6% less likely to have any Medicaid-covered service with a poisoning diagnosis (which includes overdoses) than the control group.
Health: Supportive housing had no significant impact on mortality.
Adult Medicaid beneficiaries (age 21 and older) with disabilities experiencing chronic homelessness in select Pennsylvania counties.
The PSH model integrates non-time-limited rental assistance with supportive services to promote housing stability and recovery from physical and mental health conditions. Supportive services may include case management, substance use disorder treatment, life skills training, job searching assistance, relocation assistance, and tenancy-sustaining services.
Observational study with a comparison group. Difference-in-differences analysis between beneficiaries in PSH for 180 days or more (n=1,226) and a matched cohort experiencing housing instability who did not receive PSH (n=970).
Healthcare Cost, Utilization & Value: After three years, the PSH cohort had the following outcomes relative to changes in the comparison group: Medicaid spending decreased by $145 per member per month (PMPM) (14%); ED visits decreased by 4.7 visits per 100 person-months (19%); hospitalizations decreased by 1.6 admissions per 100 person-months (44%); and use of residential substance use disorder treatment decreased by 27.3 days per 100 person-months (79%). Total service costs not given. Spending on case management services increased by $20.40 PMPM ($245 PPPY) for PSH relative to the control group.
Adults experiencing homelessness who were high-need and enrolled in a large Southern California Medicaid and Medicare health plan.
PSH program combines a long-term housing subsidy with intensive case management services and medical and non-medical support. Participants received recuperative care including shelter, meals, and transportation during a transition period while awaiting permanent housing placement. Intervention costs were $30,540 PPPY ($2,545 PMPM), including costs for those who exited the program before housing placement.
Quasi-experimental study. Regression analysis with propensity score weighting was used to compare program participants (n=162) 12 months before and 12 months after enrollment to a cohort of health plan members not enrolled in PSH (n=356).
Healthcare Cost, Utilization & Value: PSH participants used more primary and home health care after program enrollment relative to the comparison group but had fewer high-cost events and decreased use of inpatient and emergency care. Reductions in health care costs did not differ significantly between PSH and the comparison group’s total spend ($21,418 vs. $25,273). The PSH program did not save money overall.
Dually eligible Medicare and Medicaid beneficiaries in San Mateo, California.
Community Care Settings, a PSH pilot program offered by the Health Plan of San Mateo in partnership with two community-based organizations that specialize in affordable supportive housing and transitional case management. There were three targeted groups:
1) Long-term care (LTC) residents that could return to the community with long-term services and supports (LTSS), 2) individuals in acute-care or short-term rehab settings being recommended for LTC, and 3) those in the community at imminent risk of LTC placement.
The intervention cost was $2,750 PMPM including residential care facilities, care plan oversight, case management, housing retention, and LTSS.
Pre-post analysis. n=91. Changes were measured from six months before to six months after the intervention. Statistical significance was not reported.
Healthcare Cost, Utilization & Value: Average health care savings of $7,083 PMPM, including $6,207 in the costs of skilled nursing facilities and LTC. Total net program savings of $4,334 PMPM after accounting for the cost of the intervention, yielding a return-on-investment of 157%. Total net program savings was $1.4 million after accounting for $1 million in start-up costs.
Individuals involved with the criminal justice system who were experiencing homelessness. In the year before program entry, 97% of participants had been in jail or prison at least once and 57% had utilized healthcare services. In the year before enrollment, participants' criminal justice service use was estimated to cost over $4 million, or $13,259 per participant. Participant’s hospital-based care in that year cost approximately $1.5 million, or $4,772 per participant.
The Pima County Housing First (PCHF) Initiative pilot (April 2019-June 2021) provided PSH placement and case management.
Pre-post analysis examining the 12 months before and after enrollment. 314 individuals were enrolled in the PCHF Initiative between April 2019 and April 2021.
Using an intention-to-treat regression analysis framework, service utilization and associated costs were compared for a cohort of clients (n = 186) who reached their 12-month anniversary date of program enrollment.
Healthcare Cost, Utilization & Value: Healthcare costs declined by 45% from 12 months pre- to post-enrollment among 186 participants who had been enrolled for <=12 months.
Social: Among the 186 participants who had been enrolled in the PCHF Initiative for 12 or more months, criminal justice-related services declined by more than 50% and costs declined from an average of $13,640 per participant to $7,193.
Persons who were homeless and had a serious mental illness in Phoenix, Arizona. Before receiving housing subsidies, these individuals had average healthcare costs of approximately $20,000 per member per quarter.
Mercy Care Regional Behavioral Health Authority launched a scattered-site PSH program in 2014, with an integrated HF approach.
Pre-post analysis. Approximately 600 individuals. A difference-in-differences methodology was used to evaluate program outcomes.
Healthcare Cost, Utilization & Value: After enrollment, members receiving supportive housing services experienced a 24% decrease in the total cost of care when matched to a comparison group. They also had a $5,002 decrease in the total cost of care (per member per quarter) relative to a matched group of Mercy Care members not receiving housing services.
After receiving housing subsidies, members experienced a 23% ($1,509 per member per quarter) decrease in costs for professional behavioral health services, such as individual therapy and rehabilitation and a decrease of 46% ($2,277 per member per quarter) in behavioral health facility costs after receiving supportive housing. Members enrolled in the housing program experienced a 20% reduction (95 fewer hospitalizations per 1,000 members per quarter) in psychiatric hospitalizations after enrollment in the program
Adults who were homeless and members of a large public, nonprofit California Medicaid managed care plan. 64% of participants were male, 45% were non-Hispanic White, 27% were Black, and the mean enrollment age was 52 years (range 28-62 years).
Permanent supportive housing (PSH). The PSH program provided permanent housing and health and social services to members experiencing homelessness who had been recent high service utilizers (emergency rooms, hospitals, and outpatient settings).
Qualitative study. In-depth interviews were conducted with participants to collect data about their perceptions of the relationships between quality of housing and quality of life (QOL). Of the 48 eligible potential participants, 22 enrolled and completed a study interview.
Health: The housing quality and the surrounding social and built environments dominated perceived QOL. Participants attributed improvements in overall physical and mental health to being independently housed. Access to free or subsidized transportation positively influenced health-related QOL, including prompt and easy access to doctors’ appointments. Some participants reported negative experiences and worsening of physical and mental health due to being placed in substandard housing or unsafe neighborhoods.
Social: Respondents also reported improvements in food security and nutrition, due in part to better access to SNAP vouchers and food banks, and the ability to store and cook food at home. However, half of the interviewees continued to experience food insecurity after residing in their units for significant periods of time.
Homeless adults with chronic medical illnesses in Chicago.
The Housing First PSH model offered three components: 1) interim housing at a respite center after hospital discharge, 2) stable housing after recovery from hospitalization, and 3) case management in study hospitals, respite care, and housing sites. Usual-care participants received standard discharge planning from hospital social workers. Participants had on average, 18 more case manager contacts than those in usual care. The average annual incremental cost was $3,154 for housing and respite care and $183 for case management.
Randomized controlled trial. n=201 in the intervention group, and 206 in the usual care group. Study participants were followed for 18 months.
Healthcare Cost, Utilization & Value: Compared to usual care, PSH participants had: Relative reductions of 29% in hospitalizations, 29% in hospital days, and 24% in ED visits after adjusting for baseline covariates.$8,593 (26%) lower health care costs PPPY for hospitalizations, ED visits, outpatient visits, residential substance use treatment, and nursing home days. Net program savings of $6,307 (17%) PPPY in total medical, legal, housing, and case management costs; and of $9,809 PPPY among chronically homeless PSH participants. Differences in overall costs were not statistically significant.
Homeless adults with chronic medical illnesses in Chicago.
The Housing First PSH model offered three components: 1) interim housing at a respite center after hospital discharge, 2) stable housing after recovery from hospitalization, and 3) case management in study hospitals, respite care, and housing sites. Usual-care participants received standard discharge planning from hospital social workers. Participants had on average, 18 more case manager contacts than those in usual care. The average annual incremental cost was $3,154 for housing and respite care and $183 for case management.
Randomized controlled trial. n=201 in the intervention group, and 206 in the usual care group. Study participants were followed for 18 months.
Healthcare Cost, Utilization & Value: Compared to usual care, PSH participants had: Relative reductions of 29% in hospitalizations, 29% in hospital days, and 24% in ED visits after adjusting for baseline covariates.$8,593 (26%) lower health care costs PPPY for hospitalizations, ED visits, outpatient visits, residential substance use treatment, and nursing home days. Net program savings of $6,307 (17%) PPPY in total medical, legal, housing, and case management costs; and of $9,809 PPPY among chronically homeless PSH participants. Differences in overall costs were not statistically significant.
Chronically homeless adults ages 18 and older with medical illnesses and high prior acute-care use or sobering sleep-off-center visits.
Begin at Home (BAH), a Housing First PSH pilot in Seattle, offered integrated onsite medical, psychiatric, and chemical dependency services. Participants received help applying for income and food assistance benefits and developing self-sufficiency capabilities. Participants and the control group both received either medical respite or services that linked them to primary care, dental care, and behavioral health care. The cost of the program was $18,600 PPPY or $1,550 PMPM.
Pre-post analysis. Outcomes were assessed for BAH participants (n=29) one year before and after enrollment, compared to a similarly recruited control group (n=31).
Healthcare Cost, Utilization & Value: After controlling for baseline differences, average ED use was 54% lower for BAH participants than the control group (2.07 vs. 4.48 visits), while sobering center use was 86% lower (1.24 vs. 8.8 visits). Total service costs including health care and jail costs were reduced by $36,579 PPPY ($3,048 PMPM) for BAH participants versus controls. Excluding jail costs, the difference in health care costs was $35,275 ($2,940 PMPM).
Low-income adults (ages 20 to 62) who were homeless and high users of crisis services in Jacksonville (Duval County), Florida.
The Solution that Saves program at Village on Wiley offered PSH with comprehensive supportive services including case management, peer support, substance use recovery services, Medicaid and Medicare enrollment, health care enrollment, transportation, and employment services. Intervention costs were $10,058 PPPY ($838 PMPM) including housing subsidies of $8,271 PPPY ($689 PMPM) and supportive services costs of $1,788 PPPY ($149 PMPM).
Pre-post analysis. Participant data (n=68) two years before and two years after moving into PSH were assessed.
Healthcare Cost, Utilization & Value: Decreased costs of 43% for ED visits, 59% for inpatient stays, 64% for outpatient visits, 66% for inpatient mental health crisis services, and 37% for primary care at federally qualified health centers. Substance use recovery services costs increased by 134%. The total cost of services (including medical, mental health, emergency transport, county jail, and housing) decreased by 30% or $16,541 PPPY ($1,378 PMPM), though the difference was not statistically significant.
Adults (16+ years) who were experiencing homelessness.
Housing First.
Systematic review of randomized controlled trials on the effects of HF. The systematic review identified 494 articles, of which four met the study inclusion criteria.
Healthcare Cost, Utilization & Value: HF participants showed a clear reduction in non-routine use of healthcare services (ED use and hospitalization) over treatment as usual (TAU).
Health: For mental health, quality of life, and substance use, no clear differences were seen when compared with TAU.
Social: The review found that HF resulted in large improvements in housing stability.
Persons experiencing homelessness.
Permanent supportive housing with a Housing First approach.
Systematic review. 26 studies were included to evaluate the effectiveness of HFt compared to a Treatment First approach or TAU. All studies had a comparison group; eight studies had randomized control design.
Healthcare Cost, Utilization & Value: HF programs lead to reduced hospitalization and use of ED for homeless persons with disabling conditions, including HIV infection.
Health: For clients living with HIV infection, HF programs improve clinical indicators and physical and mental health and reduce mortality. The CPSTF also stated that because homelessness is associated with poverty and is more common among racial and ethnic minority populations, HF programs are likely to advance health equity.
Social: There was strong evidence that PSH with HF decreases homelessness, increases housing stability, and improves the quality of life.
People experiencing chronic homelessness.
Permanent supportive housing (PSH).
Evidence review.
Healthcare Cost, Utilization & Value: Overall, except for some evidence that PSH improves health outcomes among individuals with HIV/AIDS, the committee found that there was no substantial published evidence to demonstrate that PSH reduces health care costs.
Health: Overall, except for some evidence that PSH improves health outcomes among individuals with HIV/AIDS, the committee found that there was no substantial published evidence to demonstrate that PSH improves health outcomes.
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[6] Gromis A, Fellows I, Hendrickson JR, Edmonds L, Leung L, Porton A, Desmond M. Estimating eviction prevalence across the United States. Proc Natl Acad Sci U S A. 2022 May 24;119(21):e2116169119. doi: 10.1073/pnas.2116169119. Epub 2022 May 16. PMID: 35576463; PMCID: PMC9173767.
[7] United States Conference of Mayors. (2025, January 23). Bloomberg/CityLab: Mayors Chart an Agenda for Tackling the Housing Crisis Under Trump. Retrieved: https://www.usmayors.org/2025/01/23/icymi-national-survey-reveals-worsening-housing-crisis/#:~:text=In%20the%20past%20three%20years,concerned%20by%20rising%20housing%20costs.
[8] United States Conference of Mayors. (2025, January 23). Bloomberg/CityLab: Mayors Chart an Agenda for Tackling the Housing Crisis Under Trump. Retrieved: https://www.usmayors.org/2025/01/23/icymi-national-survey-reveals-worsening-housing-crisis/#:~:text=In%20the%20past%20three%20years,concerned%20by%20rising%20housing%20costs.
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[10] State of Homelessness: 2024 edition. National Alliance to End Homelessness. (2024, August 5). https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness/#on-the-brink
[11] de Souza, T., Andrichik, A., Prestara, E., Rush, K., Tano, C., Wheeler, M., & Abt Associates. (2023, December). 2023 Annual Homelessness Assessment Report (AHAR)r to Congress... The U.S. Department of Housing and Urban Development . https://www.huduser.gov/portal/sites/default/files/pdf/2023-ahar-part-1.Pdf
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[14] U.S. Department of Health and Human Services. (n.d.). Quality of Housing. Quality of Housing - Healthy People 2030. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/quality-housing
[15] Supportive housing 101. Corporation for Supportive Housing. (2024b, October 5). https://www.csh.org/supportive-housing-101/
[16] Supportive housing 101. Corporation for Supportive Housing. (2024b, October 5). https://www.csh.org/supportive-housing-101/
[17] Federal Funding for Homelessness Programs. National Alliance to End Homelessness. (2023, January 11). https://endhomelessness.org/ending-homelessness/policy/federal-funding-homelessness-programs/
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[19] Zur, J. et. al. Kaiser Family Foundation. Medicaid’s Role in Financing Behavioral Health Services for Low-Income Individuals. Retrieved 12/12/2024
