Letter

In Reply: We thank Ms. Reichenbach for her comments, but she misrepresents the value of supportive housing. Our study examined one impact of supportive housing: reducing the use of hospital emergency department and inpatient services during the first two years after homeless people stopped living on the streets or in shelters. As noted, 81 percent of study participants maintained housing for at least a year. The study did not measure outcomes beyond the first few years after people moved into safe and supportive homes of their own, but other research has shown that about 75 percent of tenants stay in supportive housing for at least two years—and many stay much longer. Many of those who do move out have received the support they needed to recover from addiction, stabilize their mental illness, find steady work, reunify with family members, establish new roles as community participants, and rent their own apartments—and they never return to the revolving-door of life on the streets and in shelters, treatment facilities, jails, and hospitals.

Low-demand models of supportive housing don't ignore problems related to untreated mental illness or the use of drugs or alcohol. In fact, a major focus of the service interventions in supportive housing is to help tenants recognize and seek care for these problems so that they can begin to take steps toward recovery and a successful life in the community.

We have unpublished data from our study on the types of services that the supportive housing projects provided, as well as tenants' use of mental health and substance abuse treatment services in hospital and community settings. Despite their high rates of mental illness and substance use disorders, many study participants had not received any treatment outside of a jail, emergency department, or public hospital during their years of homelessness. These chronically homeless individuals would still be living on the streets if they were required to be sober or compliant with medications as preconditions for living in supportive housing. Once chronically homeless people move into supportive housing, counselors, case managers, and primary care providers persistently and persuasively focus on helping tenants to recognize and begin to address problems related to mental illness or substance use and to access appropriate care. Notably, the supportive housing tenants who made the greatest use of these on-site support services were most likely to have the greatest reductions in the use of hospital emergency departments and inpatient care.

The values inherent in a low-demand approach to supportive housing are based on evidence that lives do change and that people with a long history of homelessness, mental illness, and addiction can take steps toward recovery. A core belief, supported by the evidence, is that the most dramatic successes begin when a homeless person moves from the streets into housing embedded with supportive services.

Our study demonstrated that for those who would not likely achieve sobriety and stability while living on the streets, supportive housing not only ended their homelessness but also reduced the costs associated with revolving-door care in hospitals and other institutions.