Supportive Housing Models

Introduction

For individuals experiencing chronic homelessness, particularly those with disabilities, mental health conditions, substance use disorders, or other complex needs, traditional housing options often prove insufficient. Permanent supportive housing (PSH) was developed to address this gap by combining affordable housing with comprehensive supportive services designed to help people maintain housing stability and improve their quality of life.

This article explores the various models of supportive housing, the evidence demonstrating their effectiveness, and the key elements that make these approaches successful. While supportive housing is not appropriate for everyone experiencing homelessness, it has proven to be a crucial intervention for those with the most significant barriers to housing stability.

What Is Supportive Housing?

Permanent supportive housing is an evidence-based housing intervention that combines affordable housing assistance with voluntary support services to address the needs of chronically homeless people. The services are designed to build independent living and tenancy skills and connect people with community-based health care, treatment, and employment services.

Core Elements of Supportive Housing

While supportive housing programs vary in their specific design, they share several essential characteristics:

• Permanent housing: Tenants have leases, pay rent (typically 30% of income), and have the same rights and responsibilities as other tenants in their community
• Affordability: Housing costs are subsidized to ensure they remain affordable to people with extremely low incomes
• Voluntary supportive services: Comprehensive services are available but not required as a condition of housing
• Housing First approach: No requirements for sobriety, treatment participation, or service engagement to access or maintain housing
• Tenant-centered: Services are individualized and focused on tenant goals and preferences
• Integrated setting: Housing enables tenants to interact with people who do not have disabilities and are not experiencing homelessness

Models of Supportive Housing

Supportive housing comes in various forms, each with distinct characteristics that may be more appropriate for different populations or contexts:

Single-Site (Congregate) Model

In this model, all units in a building are designated as supportive housing:

• Design: Purpose-built or rehabilitated buildings dedicated entirely to supportive housing
• Services: On-site services with staff often available 24/7
• Community: Creates a community of residents with shared experiences
• Examples: Downtown Emergency Service Center buildings in Seattle, Breaking Ground residences in New York City

Advantages:

• Efficient service delivery with staff on-site
• Enhanced security and monitoring capabilities
• Peer support opportunities among residents
• Ability to design physical spaces specifically for the population served
• Often more feasible in high-cost housing markets

Considerations:

• May create a sense of institutionalization
• Limited community integration
• Potential concentration of challenges in one location
• Often faces community opposition during development

Scattered-Site Model

In this approach, supportive housing units are distributed throughout regular apartment buildings and neighborhoods:

• Design: Individual apartments leased in the private rental market or set aside in affordable housing developments
• Services: Mobile support teams that visit tenants in their homes or meet at community locations
• Integration: Tenants live among people who are not in supportive housing programs
• Examples: Pathways to Housing programs, many Housing First initiatives

Advantages:

• Greater community integration and normalization
• Reduced stigma and institutional feel
• Flexibility to match housing to individual preferences
• Can be implemented more quickly without development timelines
• Often faces less community opposition

Considerations:

• More challenging service coordination
• Potential for isolation if services are insufficient
• Dependent on landlord willingness to participate
• May be difficult to implement in tight rental markets

Mixed-Model or Integrated Housing

This approach incorporates supportive housing units within larger affordable or market-rate developments:

• Design: A percentage of units (typically 15-25%) in a larger development are designated as supportive housing
• Services: Often includes some on-site services with connections to community-based providers
• Integration: Supportive housing tenants live alongside other residents in the building
• Examples: New York's ESSHI (Empire State Supportive Housing Initiative) developments, San Francisco's Mission Bay developments

Advantages:

• Balances service efficiency with community integration
• Reduces stigma and concentration of needs
• Creates mixed-income communities
• Often more financially sustainable through cross-subsidization
• Can leverage mainstream affordable housing development resources

Considerations:

• Requires careful planning for service delivery
• May create tensions between different resident populations
• Complex financing and development processes
• Requires strong property management experienced with diverse populations

"Supportive housing works because it addresses both the symptom—homelessness—and the underlying causes that made someone vulnerable to housing instability in the first place. It's not just about putting a roof over someone's head; it's about creating the conditions for them to thrive."

Supportive Services in Supportive Housing

The "supportive" element of supportive housing is as important as the housing itself. While services vary based on population needs and program design, they typically include:

Case Management

The foundation of most supportive housing service models:

• Individualized assessment and service planning
• Regular check-ins and relationship building
• Crisis intervention and problem-solving
• Coordination across multiple service systems
• Advocacy and system navigation

Health Services

Addressing physical and behavioral health needs:

• Primary care connections and coordination
• Medication management assistance
• Mental health services (therapy, psychiatric care)
• Substance use treatment and harm reduction
• Health education and preventive care

Independent Living Skills

Building capabilities for housing stability:

• Budgeting and financial management
• Housekeeping and home maintenance
• Cooking and nutrition
• Technology skills and digital literacy
• Time management and appointment keeping

Community Integration

Fostering connections beyond housing:

• Social skills development
• Recreational and community activities
• Volunteer opportunities
• Cultural engagement
• Spiritual connections based on individual preferences

Employment and Education

Supporting meaningful activity and income:

• Vocational assessment and planning
• Job readiness and search assistance
• Supported employment opportunities
• Educational advancement
• Benefits counseling and work incentives planning

Evidence of Effectiveness

Permanent supportive housing has been extensively studied, with research consistently demonstrating positive outcomes across multiple domains:

Housing Stability

The primary goal of supportive housing is to end homelessness, and research shows it succeeds:

• Housing retention rates typically range from 75-85% at one year and beyond
• A 2015 RAND Corporation study found that 82% of participants in Los Angeles County's Housing for Health initiative remained housed after one year
• New York's supportive housing programs consistently demonstrate retention rates above 85%

Health Outcomes

Supportive housing significantly impacts health and healthcare utilization:

• 50-60% reductions in emergency department visits
• Decreased inpatient hospitalizations (both medical and psychiatric)
• Improved management of chronic conditions
• Increased engagement with primary care and preventive services
• Reduced mortality rates compared to those remaining homeless

Mental Health and Substance Use

Research shows improvements in behavioral health outcomes:

• Reduced psychiatric symptom severity
• Decreased substance use and related harms
• Increased treatment engagement and medication adherence
• Improved quality of life and self-reported well-being

Criminal Justice Involvement

Supportive housing reduces interactions with law enforcement and incarceration:

• Fewer arrests and jail days
• Reduced recidivism for those with criminal histories
• Decreased public order offenses related to survival activities

Cost-Effectiveness

Multiple studies demonstrate that supportive housing is cost-effective:

• A landmark 2002 study in New York found that each supportive housing unit saved $16,282 annually in public costs
• Denver's Social Impact Bond initiative showed net savings of $15,733 per person annually
• Los Angeles County's Housing for Health program reduced public spending by 20% for participants
• Cost savings primarily come from reduced use of emergency services, hospitalizations, and criminal justice systems

Populations Served by Supportive Housing

While initially developed for single adults with serious mental illness, supportive housing has been adapted for various populations:

Chronically Homeless Individuals

The primary population served by most supportive housing programs:

• People with long-term homelessness (typically 12+ months or multiple episodes)
• Those with disabilities, including serious mental illness, substance use disorders, and physical disabilities
• High utilizers of emergency systems and institutional care

Families with Complex Needs

Adaptations for families experiencing chronic homelessness:

• Parents with disabilities or behavioral health needs
• Families involved with child welfare systems
• Survivors of domestic violence with trauma-related needs
• Services include parenting support and child-specific interventions

Youth and Young Adults

Specialized models for younger populations:

• Youth aging out of foster care
• LGBTQ+ youth experiencing homelessness
• Young adults with emerging mental health conditions
• Services emphasize developmental needs, education, and employment

Older Adults

Growing focus on aging homeless populations:

• People experiencing homelessness in their 50s often have health conditions typical of those 20 years older
• Services include health management, activities of daily living support, and end-of-life planning
• Physical design considerations for mobility limitations

Justice-Involved Individuals

Specialized supportive housing for those exiting incarceration:

• People with histories of cycling between jails/prisons and homelessness
• Services include legal support, community supervision coordination, and reentry assistance
• Often implemented through partnerships with criminal justice agencies

Financing Supportive Housing

Supportive housing typically requires multiple funding sources for both capital development and ongoing operations:

Capital Funding

Resources for acquiring, constructing, or rehabilitating housing:

• Low Income Housing Tax Credits (LIHTC)
• HOME Investment Partnerships Program
• Community Development Block Grants (CDBG)
• State and local housing trust funds
• Federal Home Loan Bank Affordable Housing Program
• Private philanthropy and social impact investments

Operating Subsidies

Funding to ensure ongoing affordability:

• HUD Continuum of Care (CoC) rental assistance
• Housing Choice Vouchers (Section 8)
• Project-based Section 8 contracts
• State and local rental subsidy programs
• Operating reserves funded during development

Services Funding

Resources for supportive services:

• Medicaid (particularly in states with supportive housing services benefits)
• HUD Continuum of Care supportive services funding
• Substance Abuse and Mental Health Services Administration (SAMHSA) grants
• State and local behavioral health funding
• Veterans Affairs Supportive Housing (VASH) case management
• Private foundations and corporate giving

Innovative Financing Mechanisms

New approaches to funding supportive housing:

• Pay for Success/Social Impact Bonds that fund services based on achieved outcomes
• Hospital community benefit investments
• Medicaid managed care reinvestment
• Cross-system funding partnerships (criminal justice, child welfare, etc.)

Implementation Challenges and Solutions

Despite its effectiveness, implementing supportive housing faces several challenges:

Community Opposition

Addressing "Not In My Backyard" (NIMBY) resistance:

• Challenge: Neighborhood concerns about property values, safety, and community character
• Solutions: Early community engagement, high-quality design, clear operational plans, involving neighbors in planning, sharing success stories from similar developments

Housing Market Constraints

Finding appropriate housing in competitive markets:

• Challenge: Limited affordable housing stock, landlord reluctance, high development costs
• Solutions: Landlord incentive programs, master leasing approaches, utilizing public land for development, inclusionary zoning policies

Service Integration

Coordinating across multiple systems:

• Challenge: Siloed funding streams, differing eligibility requirements, fragmented service systems
• Solutions: Cross-system partnerships, blended funding approaches, data-sharing agreements, co-location of services

Workforce Development

Building and maintaining a skilled supportive housing workforce:

• Challenge: Staff recruitment and retention, burnout, training needs
• Solutions: Competitive compensation, career advancement pathways, robust training and supervision, peer specialist integration, trauma-informed organizational practices

Balancing Autonomy and Support

Respecting tenant rights while providing needed services:

• Challenge: Tension between housing stability and tenant choice, particularly around behaviors that may impact others
• Solutions: Clear lease agreements, harm reduction approaches, motivational engagement strategies, crisis response protocols, eviction prevention practices

The Future of Supportive Housing

Supportive housing continues to evolve in several important directions:

Integration with Mainstream Housing

Moving beyond specialized developments:

• Incorporating supportive housing units within regular affordable housing
• Developing mixed-income, mixed-use communities
• Creating "moving on" strategies for tenants who no longer need intensive services

Healthcare Integration

Strengthening connections with healthcare systems:

• On-site healthcare services in larger developments
• Telehealth integration for scattered-site programs
• Value-based payment models that recognize housing as healthcare
• Hospital and healthcare system investment in supportive housing

Trauma-Informed Design

Incorporating trauma principles into physical environments:

• Building design that promotes safety and choice
• Sensory-friendly spaces
• Biophilic elements that connect to nature
• Community spaces that facilitate connection while respecting boundaries

Technology Integration

Leveraging technology to enhance supportive housing:

• Smart home features for aging in place
• Digital service delivery platforms
• Data systems that coordinate care across providers
• Virtual reality for skill building and community connection

Conclusion

Permanent supportive housing represents one of the most significant innovations in addressing chronic homelessness in recent decades. By combining affordable housing with flexible, voluntary supportive services, this approach has demonstrated remarkable success in helping people with complex needs achieve housing stability and improve their quality of life.

The evidence is clear: supportive housing not only ends homelessness for those most vulnerable but does so in a cost-effective manner that reduces public system costs. While not appropriate for everyone experiencing homelessness—many people simply need affordable housing without intensive services—supportive housing is an essential component of any comprehensive strategy to end homelessness.

As communities continue to develop and refine supportive housing models, the focus should be on expanding capacity, improving quality, enhancing integration with mainstream systems, and ensuring that these interventions are accessible to all who need them. With sufficient political will and resource allocation, supportive housing offers a proven path to ending chronic homelessness and creating communities where everyone has the opportunity to thrive.

References & Further Reading

1. National Academies of Sciences, Engineering, and Medicine. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. National Academies Press, 2018. https://doi.org/10.17226/25133
2. Corporation for Supportive Housing. "Supportive Housing 101." CSH, 2023. https://www.csh.org/supportive-housing-101/
3. Culhane, D.P., Metraux, S., and Hadley, T. "Public Service Reductions Associated with Placement of Homeless Persons with Severe Mental Illness in Supportive Housing." Housing Policy Debate, vol. 13, no. 1, 2002, pp. 107-163. https://doi.org/10.1080/10511482.2002.9521437
4. RAND Corporation. "Housing for Health: A State-of-the-Art Program for Reducing Homelessness in Los Angeles County." RAND, 2018. https://www.rand.org/pubs/research_reports/RR1694.html
5. National Alliance to End Homelessness. "Permanent Supportive Housing." NAEH, 2023. https://endhomelessness.org/resource/permanent-supportive-housing/
6. Tsemberis, S. "Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction." Hazelden Publishing, 2010. https://www.pathwayshousingfirst.org/
7. U.S. Department of Housing and Urban Development. "Supportive Housing for Persons with Disabilities." HUD, 2023. https://www.hud.gov/program_offices/housing/mfh/progdesc/disab811
8. Rog, D.J. et al. "Permanent Supportive Housing: Assessing the Evidence." Psychiatric Services, vol. 65, no. 3, 2014, pp. 287-294. https://doi.org/10.1176/appi.ps.201300261
9. Denver Social Impact Bond Initiative. "Denver Supportive Housing Social Impact Bond: Housing Stability Outcomes." Urban Institute, 2020. https://www.urban.org/research/publication/denver-supportive-housing-social-impact-bond-initiative