Experts make the case for 'housing first' approach to homelessness

In a new perspective published today in the New England Journal of Medicine, five experts, including Dr. David Buck with Baylor College of Medicine, make the argument for Housing First as an approach to end homelessness across the country.

The Housing First approach offers permanent supportive housing to the homeless without prerequisites that traditional approaches require, such as psychiatric or substance use treatment or attaining sobriety before receiving housing. The approach also combines financial support for housing with offers of psychiatric, medical and social rehabilitative support. Studies have shown that this type of intervention has resulted in faster exits from homelessness and more time spent in housing compared to traditional approaches.

However, authors of the paper caution against the argument that this approach provides cost savings, arguing that high-quality randomized, controlled trials have not demonstrated net cost savings for this approach. The authors say that there should be no expectation that these types of health and social services save money, but instead should focus on the quality-adjusted life-years gained. They argue that insisting on cost savings of such programs devalues the lives of homeless people.

Other institutions who contributed to the perspective include the University of Alabama at Birmingham School of Medicine, Harvard Medical School and the University of California, San Francisco.

"We see Housing First as the indispensable strategy for ending homelessness," said Buck, professor of family and community medicine at Baylor. "We didn't want people to discredit programs when claims about economic costs don't hold up under scrutiny."

Instead, Buck and his co-authors insist that a more sound argument to favor the Housing First approach should look at scientific research, economic considerations and moral values. Scientific research has shown that this approach is more effective in promoting residential stability. From an economic perspective, the program has a relatively low cost of $8,000 to $18,000 per year of housing, with returns on investment being partially offset by the use of emergency medical and judicial services, as well as the creation of a more livable community and more welcoming space for commercial development. The authors estimate $100,000 to $150,000 per quality-adjusted life-year for selected medical interventions. Finally, from an ethical perspective it fulfills a collective responsibility to remediate persistent homelessness in one of the wealthiest countries in the world.

Buck is the founder of Healthcare for the Homeless – Houston, which offers health services for the homeless in Houston. Buck also founded and is president of Patient Care Intervention Center, which aims to improve healthcare quality and costs for the underserved through data integration and care coordination. He also directs the Houston Outreach Medicine, Education and Social Services (HOMES) clinic, which is managed by medical students at Baylor and the McGovern Medical School at The University of Texas Health Science Center and College of Pharmacy students at the University of Houston. HOMES is a clinic of Healthcare for the Homeless – Houston.

The HOMES clinic aims to provide acute care for the homeless on Sundays when they would otherwise have access to only an emergency room. While the clinic does not provide long-term care, patients are referred to Healthcare for the Homeless – Houston for their primary care. Since it's opening in 1999, the shared leadership of the HOMES clinic among the three healthcare institutions has provided care for more than 5,000 patients and has involved thousands of student volunteers.