An intervention that provides housing for homeless persons with severe alcohol problems without requiring abstinence from drinking was associated with reduced health care use and costs and a decrease in the use of alcohol, according to a study in the April 1 issue of JAMA.
Chronically homeless people with severe alcohol problems are costly to the public because of their high use of publicly funded health and criminal justice systems resources. Typical interventions such as shelters, abstinence-based housing and treatment programs fail to reverse these patterns for this population, according to background information in the article. The provision of housing reduces hospital visits, admissions and duration of hospital stays among homeless individuals. One type of supportive housing, called Housing First (HF), removes the requirements for sobriety, mandatory attendance to alcohol treatment programs, and other barriers to housing entrance.
Mary E. Larimer, Ph.D., of the University of Washington, Seattle, and colleagues evaluated a HF program for chronically homeless individuals with severe alcohol problems, comparing the costs for housed participants with wait-list controls and noting any changes in reported alcohol use. The study included 95 housed participants (with drinking permitted in the residence) and 39 wait-list control participants, who were enrolled between November 2005 and March 2007. The researchers examined the use and cost of services for study participants (such as jail bookings, days incarcerated, shelter and sobering center use, hospital-based medical services, publicly funded alcohol and drug detoxification and treatment, emergency medical services and Medicaid-funded services).
In the year prior to the study, housed participants accrued median (midpoint) costs of $4,066 per month per individual, with a total of $8,175,922 in costs accrued by the 95 individuals for the year. After receiving housing, individual median costs per month declined after 6 months ($1,492) and again at 12 months ($958), and total costs for the housed group for the year after enrollment in housing were $4,094,291, a reduction in total costs by more than $4 million.
Cost offsets for HF participants at 6 months, in comparison with wait-list controls and accounting for the cost of housing, averaged $2,449 per person per month, with HF participants accruing approximately 53 percent less costs compared with controls over the first 6 months of the study. In addition, there was an approximate 2 percent decrease per month in daily drinking while participants were housed.
"… the current study adds to the body of literature in support of HF. Reductions in health care and criminal justice system use and costs and alcohol consumption support expansion and replication of this low-threshold approach. Repeated unsuccessful participation in traditional programs such as abstinence-based or mandated treatment, and high rejection rates of these programs by chronically homeless individuals with alcohol problems, suggests that less conventional approaches such as HF are also needed," the researchers write.
"Findings suggest that permanent, rather than temporary, housing may be necessary to fully realize these cost savings, because benefits continued to accrue the longer these individuals were housed. Findings support strategies to retain these individuals in housing, including offering on-site medical and mental health services, supportive case managers, and minimal rules and regulations pertaining to their housing."
(JAMA. 2009;301:1349-1357. Available pre-embargo to the media at www.jamamedia.org)
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