Housing First: Principles and Evidence

Introduction

For decades, the traditional approach to addressing homelessness followed a "treatment first" or "staircase" model. People experiencing homelessness were expected to progress through a series of steps—typically including sobriety, treatment compliance, and transitional housing—before being deemed "housing ready." This approach created significant barriers to housing stability for many people, particularly those with complex needs.

Housing First fundamentally reversed this paradigm. Developed in the early 1990s and refined over subsequent decades, Housing First is both a specific program model and a broader philosophy that has transformed homelessness services worldwide. This article explores the core principles of Housing First, the evidence supporting its effectiveness, and how it has been implemented across different contexts and populations.

Core Principles of Housing First

Housing First is guided by several fundamental principles that distinguish it from traditional approaches:

1. Immediate Access to Permanent Housing Without Preconditions

The defining feature of Housing First is that it provides immediate access to permanent housing without requiring sobriety, treatment participation, income, or other "readiness" conditions. This principle recognizes housing as a basic human right and a foundation for stability, not a reward for compliance.

2. Consumer Choice and Self-Determination

Housing First programs emphasize client choice in housing type and location, as well as in service participation. This respect for autonomy increases engagement and promotes dignity.

3. Recovery Orientation

While not mandating treatment, Housing First programs offer a range of supportive services focused on promoting recovery from trauma, substance use disorders, mental health conditions, and the experience of homelessness itself.

4. Individualized and Person-Centered Support

Services are tailored to each individual's unique needs, preferences, and goals, rather than following a standardized program structure.

5. Social and Community Integration

Housing First aims to help people become part of their communities through scattered-site housing, community-based services, and support for developing social connections and meaningful activities.

The Evidence Base for Housing First

Housing First has been extensively studied across multiple countries, populations, and implementation contexts. The evidence consistently demonstrates several key outcomes:

Housing Retention

Housing First consistently achieves higher housing retention rates compared to traditional approaches:

• The original Pathways to Housing program in New York City demonstrated 85-90% housing retention rates over two years
• Canada's At Home/Chez Soi randomized controlled trial found that Housing First participants spent 73% of their time stably housed over two years, compared to 32% for treatment-as-usual participants
• Finland's national Housing First policy has contributed to it becoming the only European country where homelessness has consistently decreased

Cost-Effectiveness

Multiple studies have demonstrated cost savings or cost neutrality when comparing Housing First to traditional approaches:

• Reduced use of emergency services, hospitalizations, and interactions with the criminal justice system often offset most or all program costs
• A 2017 analysis found that Housing First in Denver saved an estimated $15,733 per person annually in public costs
• The Canadian At Home/Chez Soi study found that every $10 invested in Housing First services resulted in average savings of $9.60 for high-need participants and $3.42 for moderate-need participants

Health and Well-being Outcomes

Research shows improvements in various health and quality-of-life measures:

• Reduced emergency department visits and hospitalizations
• Improved mental health symptoms and quality of life
• Increased engagement with primary healthcare and preventive services
• Greater food security and improved nutrition

Substance Use Outcomes

Contrary to concerns that Housing First might enable substance use, research shows:

• Similar or better substance use outcomes compared to treatment-first approaches
• Increased engagement in substance use treatment over time (when offered without coercion)
• Reduced harm from substance use through safer consumption environments

Community Integration

Studies indicate improvements in social inclusion and community participation:

• Increased social support networks
• Greater participation in community activities
• Reduced experiences of stigma and discrimination

"Housing First is one of the most significant innovations in human services in recent decades. It represents a paradigm shift in how we understand and address homelessness—from managing it as a personal failing to ending it by addressing its root cause: lack of housing."

Housing First Across Different Populations

While initially developed for people experiencing chronic homelessness with serious mental illness, Housing First has been successfully adapted for diverse populations:

Chronically Homeless Individuals

The strongest evidence base exists for Housing First programs serving people with long histories of homelessness and complex needs:

• Typically implemented through permanent supportive housing models
• Intensive case management ratios (often 1:10 or lower)
• Comprehensive wraparound services including mental health, substance use, physical health, and life skills support

Families Experiencing Homelessness

Housing First principles have been adapted for family homelessness:

• Rapid re-housing programs that quickly move families into permanent housing with short-term rental assistance
• Services focused on housing stability, employment, child well-being, and family functioning
• Demonstrated effectiveness in reducing shelter stays and preventing returns to homelessness

Youth Experiencing Homelessness

Adaptations for youth (16-24) incorporate developmental considerations:

• Greater emphasis on education, employment, and life skills development
• Attention to family reconnection when appropriate
• Peer support components and youth-specific engagement strategies
• Flexible housing options including scattered-site apartments, shared housing, and host homes

Veterans

The U.S. Department of Veterans Affairs has widely implemented Housing First:

• HUD-VASH (Housing and Urban Development-VA Supportive Housing) program combines Housing First with specialized veteran services
• Contributed to a 50% reduction in veteran homelessness between 2010-2019
• Addresses military-specific trauma and transition challenges

Implementation Models and Variations

Housing First has been implemented through several program models:

Scattered-Site Housing with Mobile Support

The original Pathways model uses regular apartments throughout the community:

• Participants hold standard leases in private market housing
• Mobile support teams provide services in homes and community settings
• Promotes community integration and normalization
• Typically uses a rent subsidy where participants contribute 30% of income toward rent

Single-Site or Congregate Housing

Some Housing First programs operate in dedicated buildings:

• All units in the building house formerly homeless individuals
• On-site services and 24/7 staffing
• May be preferred for individuals with very high support needs
• Examples include Seattle's Downtown Emergency Service Center and San Francisco's Mission Housing

Rapid Re-Housing

Applies Housing First principles with time-limited assistance:

• Immediate housing placement without preconditions
• Short-term rental assistance (typically 3-24 months)
• Less intensive services focused on housing stability and self-sufficiency
• Most effective for people with moderate needs and some income potential

System-Wide Housing First Approaches

Some communities have implemented Housing First as a system-wide philosophy:

• All programs within the homelessness response system adopt Housing First principles
• Coordinated entry systems prioritize housing placement without barriers
• Multiple program types operate within a Housing First framework
• Examples include Finland, Medicine Hat (Canada), and Houston (USA)

Common Challenges and Misconceptions

Despite strong evidence, Housing First implementation faces several challenges:

Housing Availability and Affordability

The most significant barrier to Housing First implementation is often the lack of affordable housing:

• Limited housing stock in many high-cost markets
• Insufficient rental subsidies to bridge affordability gaps
• Landlord reluctance to participate in programs
• Need for concurrent affordable housing development strategies

Fidelity to Core Principles

Programs that call themselves "Housing First" don't always adhere to all core principles:

• Some maintain service participation requirements despite Housing First branding
• Others provide housing without adequate supportive services
• Fidelity assessment tools help ensure programs truly follow Housing First principles

Misconception: "Housing Only"

A common misconception is that Housing First means simply providing housing without services:

• Authentic Housing First programs offer robust, voluntary supportive services
• Service engagement typically increases over time as trust develops
• The approach emphasizes housing stability as a platform for addressing other needs

Misconception: "One Size Fits All"

Another misconception is that Housing First is presented as the only solution:

• Housing First is most evidence-based for ending homelessness but works best as part of a comprehensive system
• Prevention, affordable housing development, and poverty reduction remain essential
• Different Housing First models serve different population needs

The Future of Housing First

Housing First continues to evolve in several important directions:

Integration with Healthcare Systems

Growing recognition of housing as a social determinant of health is leading to new partnerships:

• Medicaid funding for housing support services in some states
• Hospital investments in Housing First programs
• Integration of primary care with housing services

Racial Equity Focus

Addressing racial disparities in homelessness through culturally responsive Housing First:

• Culturally specific program adaptations
• Addressing systemic racism in housing systems
• Diversifying leadership and staff in Housing First programs

Scaling and Systems Change

Moving from individual programs to system-wide implementation:

• Coordinated funding streams aligned with Housing First principles
• Policy reforms to remove barriers to housing
• Integration with broader affordable housing strategies

Conclusion

Housing First represents a paradigm shift in addressing homelessness—from managing it as a personal failing to ending it by addressing its root cause: lack of housing. The substantial evidence base supporting Housing First demonstrates that providing immediate access to permanent housing without preconditions, coupled with appropriate supportive services, is the most effective approach to ending homelessness for a wide range of populations.

While Housing First is not a complete solution to homelessness on its own—broader structural issues like affordable housing shortages and poverty must also be addressed—it provides a proven foundation for effective homelessness response systems. By removing barriers to housing and respecting individual choice and dignity, Housing First not only ends homelessness more effectively than traditional approaches but does so in a way that affirms the humanity of people experiencing housing instability.

As communities continue to implement and refine Housing First approaches, the evidence suggests that we have a clear path forward for significantly reducing homelessness when there is sufficient political will and resource allocation to bring these proven solutions to scale.

References & Further Reading

1. Tsemberis, Sam. "Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction." Hazelden Publishing, 2010. https://www.pathwayshousingfirst.org/
2. Tsemberis, Sam, Gulcur, Leyla, and Nakae, Maria. "Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals with a Dual Diagnosis." American Journal of Public Health, Vol. 94, No. 4, April 2004. https://ajph.aphapublications.org/doi/full/10.2105/AJPH.94.4.651
3. Goering, Paula et al. "National At Home/Chez Soi Final Report." Mental Health Commission of Canada, 2014. https://www.mentalhealthcommission.ca/English/at-home
4. Pleace, Nicholas. "Housing First Guide Europe." Y-Foundation, 2016. https://housingfirsteurope.eu/guide/
5. Y-Foundation. "A Home of Your Own: Housing First and Ending Homelessness in Finland." Y-Foundation, 2017. https://ysaatio.fi/en/housing-first-finland
6. Perlman, Jennifer and Parvensky, John. "Denver Housing First Collaborative: Cost Outcomes and Impact on the Community." Colorado Coalition for the Homeless, 2017. https://www.coloradocoalition.org/research
7. U.S. Department of Veterans Affairs. "HUD-VASH Program." VA Homeless Programs, 2024. https://www.va.gov/homeless/hud-vash.asp
8. National Alliance to End Homelessness. "Housing First." NAEH, 2022. https://endhomelessness.org/resource/housing-first/
9. Padgett, Deborah K., Henwood, Benjamin F., and Tsemberis, Sam. "Housing First: Ending Homelessness, Transforming Systems, and Changing Lives." Oxford University Press, 2016. https://global.oup.com/academic/product/housing-first-9780199989805
10. U.S. Department of Housing and Urban Development. "Housing First in Permanent Supportive Housing." HUD Exchange, 2014. https://www.hudexchange.info/resource/3892/housing-first-in-permanent-supportive-housing-brief/