The Cost of Homelessness:
The Value of
Investment in Housing
Support Services
in Halifax
June 2006
Submitted by
Cities & Environment Unit,
School of Planning
Dalhousie University
Funded by the Government of Canada, National
Homelessness Initiative, Supporting Communities Partnership
Initiative (SCPI) Program
A community research project supporting the Community Action on
Homelessness Research Group coordinated by
Social Policy
Development, Community Development Services of Halifax Regional
Municipality
The Cost of Homelessness and the Value of Investment in
Housing Support Services in Halifax Regional Municipality
June 2006
Submitted by
Cities & Environment Unit
Dalhousie University
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
2
The Cost of Homelessness and the Value of Investment in
Housing Support Services in Halifax Regional Municipality
June 2006
Research Team
Director
Frank Palermo
Research Investigators
Beata Dera
Delaine Clyne
Research Contributors
Heather Ternoway
Beth Lewis
Student Assistants
Rachel Harrison
Robert Kostiuk
Advisors
Barbara Nehiley
Rebecca Koeller
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
3
TABLE OF CONTENTS
Acknowledgements
2
Executive Summary
3
List of Tables and Figures
5
1
6
Introduction
Proposition
Methodology
2 Supporting the Proposition: Trends in Literature
Establishing the Context for Homelessness
Housing First
Economic Benefits of Providing Supportive Housing and Housing First
Social Benefits of Providing Supportive Housing and Housing First
10
3 Supportive Housing in Metro Halifax: Local Profile
Who is Homeless in Halifax?
Service Providers Interview Outcomes and Observations
Perceived Service Gaps
Supportive Housing Cost Effectiveness: Metro Halifax Application
21
4 Supportive Housing: Making the Decision
Understanding the Tool
Housing Approaches in Metro Halifax: Comparing the Costs
Metro Halifax Examples
31
5
39
Conclusions
Appendices
41
Bibliography
Annotated Bibliography: Selected Literature Review
Housing First Programs in the United States
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
1
Acknowledgements
Researchers from the Cities & Environment Unit would like to thank all of service providers who
generously gave their time, and provided valuable information and insights into supportive housing in
Metro Halifax: Sherri Lecker, Adsum House; Carol Charlebois, Metro Non-Profit Housing
Association; Cathy Crouse, Metro Community Housing Association; Michael Humphreys and John
Connor, Metro Turning Point Center; Linda Wilson, Homebridge Youth Society; Shannon Bond, Barry
House; Carol Anne Brennan, Regional Residential Services Society; and, Joanne Bernard, Alice
Housing.
We would also like to acknowledge Tim Crooks from Phoenix House and Catherine Sloan from Laing
House for participating in the study.
We would like to extend a note of special thanks to Barbara Nehiley and Rebecca Koeller from HRM
for guiding us through a sometimes complex, but always interesting, research project. Thank-you also
to Kasia Tota for sharing her experiences.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
2
Executive Summary
The provision of supportive housing substantially reduces the burden on hospitals, psychiatric care,
prisons and jails. This trend had been observed nationally and internationally. People in supportive
housing on average spend only one third as much time in these facilities as the homeless population.
While the cost may not always be obvious because it is spread over different departments and budgets,
these are expensive services. The actual costs vary, but the pattern is clear: homelessness is expensive,
and substantial broad cost savings of about 40% can be achieved by investing in supportive housing.
This study is about homelessness and the costs and benefits of providing supportive housing in Metro
Halifax. The researchers propose that investing in supportive housing for the homeless in Metro
Halifax using a “Housing First” approach, where the supportive housing is permanent, offered
immediately, with low entry demands, is cost effective and socially beneficial. Supportive housing in
this research is defined as a form of affordable housing with support services attached to help a client
perform daily living functions that may not otherwise be possible. The Housing First concept places
priority on providing permanent housing immediately with few questions asked. This approach appears
to make social and economic sense, where the most vulnerable and costly segment of the homeless
population is taken care of first.
The methodology for the research was two-pronged: a brief literature review which culminated in a
description of key trends and an annotated bibliography; as well as interviews with local providers of
supportive housing. Fourteen of the nineteen studies reviewed for this research make a compelling case
for supportive housing. Homeless individuals in shelters or on the streets place a heavy burden on
expensive health care, social services, and the criminal justice system. One study calculated that in
New York City, 95% of the homeless use public health services, 76% used outpatient or inpatient
services at the local public hospital, 47% use substance treatment services, 65% use mental health
services outside the hospital system; and 40% receive health care while in the county jail.
Culhane discovered that in New York, individuals placed into supportive housing were associated with
a reduction in service use of $16,282 per housing unit per year. A study conducted on the costs of
homelessness in British Columbia had similar findings. It determined that society could save between
$8,000 and $12,000 dollars per year per person. Culhane (2001), also calculated that a homeless person
with mental illness living on the street in New York costs the government approximately $41,000 a
year for shelter, social and health services. A shelter bed alone costs between $27,000 and $35,000 per
year. The Housing First program costs $22,000 per client per year for both housing and treatment.
Various studies also looked at the social benefits of supportive housing and found that overall
participants felt more independent, had greater feelings of well being and had a better outlook for the
future. Some participants attributed staying out of jail and controlling their addictions to having stable,
supportive housing. Participants in the Housing First program had greater perceived choice and control
in treatment programs, which were made available but not mandatory. They also had an 80% housing
retention rate, which is considered very significant for a group of formerly homeless people with
serious mental illness.
Local research was conducted with nine supportive housing and shelter providers through individual
interviews in Metro Halifax. Selection of providers was based on finding a sample of facilities that
serve a range of clients. The intent of this part was to compile a snapshot of existing supportive housing
services, including the supports they provide and their associated costs. The data gathered regarding
costs per person, came directly from the providers based on per diem rates funded by the Department of
Community Services.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
3
The lowest cost obtained in the local supportive housing providers interviews, $11 per day for
supported apartments, is subsidized by some of the other programs operated by that organization. Other
supported apartment costs range from $23 to $44, while small options and group homes typically cost
$100 to $200 for middle range services and $250 to $560 for very high needs residents, such as
individuals with both intellectual and physical disabilities or youth with intense emotional and
behavioral difficulties.
Surprisingly, none of the service providers are functioning over capacity nor do they appear to be faced
with long waiting lists. The organizations funded entirely by the Department of Community Services
receive referrals from the Department and are not aware how extensive the waiting lists are. It is
difficult to discern whether or not existing services are adequate in terms of the numbers of homeless. It
is more apparent, however, that the diversity of needs among the homeless is not being met by current
organizations. According to the service providers, there is a substantial need for supportive housing for
families with children, youth with intense behavioral issues, older individuals, youth, and those with
mental health and addiction issues.
A cost savings comparison was designed for this study to determine the approximate value of investing
in supportive housing in Metro Halifax. Costs for six major public services typically accessed by
homeless individuals: shelter, jail, prison, hospital, psychiatric hospital, and supportive housing – were
calculated per person per day. The frequency of service usage (days per year) was derived from
Culhane’s study in New York and applied to Metro Halifax. The findings from this cost saving
comparison were that in Metro Halifax a cost savings of 41% per homeless person could be achieved
by investing in supportive housing.
The final part of this study provides a tool, which compares the cost effectiveness and benefits of
various homelessness strategies. In order for the tool to be effective it relies on accurate data of who the
local homeless are, what services already exist, what the capacity of those services is, what needs are
currently unmet and the current cost of services. A series of local facts, figures and information is
required in order to make the investment decision knowingly.
This tool is a first step. It is based on data gathered locally from service providers as well as
information gathered from relevant studies. It consists of three parts, intended to work together:
1. Comparative costs of housing approaches provides a way of assessing and comparing costs for
emergency shelters, supportive housing and Housing First approaches.
2. Use and other costs of providing various housing approaches outlines a way of assessing and
comparing costs for hospital, psychiatric hospital, jail and prison, incurred by someone in a shelter,
supportive housing, or in a Housing First model.
3. Social benefits of providing various housing approaches briefly outlines key social benefits
associated with each housing approach, to serve as a qualitative complement to the financial data.
This study has provided enough local data about supportive housing and international data about
Housing First to know generally that both are a good social and economic investment. However, much
more specific local data related to the cost effectiveness of providing supportive housing in the local
context is needed.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
4
List of Tables and Figures
Tables
Table 1: The Effectiveness of Various Housing First Programs.
Table 2: Data Related to Homelessness Gathered for New York Action Plan
Table 3: Comparative Costs of Various Service Sectors by City (costs per person per day)
Table 4: Service Use by a Homeless Individual in a Shelter Compared to a Formerly Homeless Person
in Supportive Housing.
Table 5: Supportive Housing Costs, Shelters and Funding Sources in Metro Halifax
Table 6: Public Facility Costs per Person per Day in Metro Halifax
Table 7: Public Facility Use in Metro Halifax, Days per Person/Year
Table 8: Clients Served by Existing Metro Halifax Supportive Housing Facilities
Table 9: Comparative Costs of Housing Approaches
Table 10: Costs and Use of Various Housing Approaches
Table 11: Social Benefits of Providing Various Housing Approaches
Table 12: Comparative Costs of Housing Approaches in Metro Halifax
Table 13: Costs and Use of Various Housing Approaches in Metro Halifax
Table 14: Local Information Needed about Homelessness and Indicators of Success.
Figures
Figure 1. Housing First: Stages From Homelessness to Re-integration into the Community.
Figure 2. Comparative Costs of Public Facility Use in Metro Halifax.
Figure 3. Comparison of Total Annual Costs of Public Facilities per Person in Metro Halifax.
Figure 4. Tool Overview
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
5
1
Introduction
The provision of supportive housing substantially reduces the burden on hospitals, psychiatric care,
prisons and jails. This trend had been observed nationally and internationally. People in supportive
housing on average spend only one third as much time in these facilities as the homeless population.
While the cost may not always be obvious because it is spread over different departments and budgets,
these are expensive services. The actual costs vary, but the pattern is clear: homelessness is expensive,
and substantial broad cost savings of about 40% can be achieved by investing in supportive housing.
There is a broad spectrum of possibilities associated with supportive housing. These range from
temporary supportive housing options, to supportive housing offered as part of a continuum of care
(where the client graduates from the shelter to transitional housing to supportive housing and
eventually to minimal or no support affordable housing) and finally to a “Housing First” approach
where permanent supportive housing is provided immediately (eliminating the progression through
other housing stages). Growing evidence points to the wisdom both financially and socially of
investing in the Housing First approach. That is, providing permanent supportive housing immediately,
with very low entry demands for the clients.
The way to solve homelessness is to provide more homes, giving people a long-term stable
environment. The accepted practice, however, has been to provide shelters and transitional housing for
the homeless, attempting only to meet the day-to-day and emergency needs of these individuals.
“The shelter system has become the immediate answer for too many problems. Don't
know where to send that guy just released from prison? The city shelter ought to have a
bed. And that couple discharged from a mental-health facility? Send 'em over to the
homeless shelter. It's like the default system.”1
- Dr. Dennis Culhane
Numerous studies have identified, nationally (Pomeroy 2005, Golden 1995, Eberle 2001) and
internationally (Culhane 2001, Berry 2003, Lewin Group 2004), that supportive housing is one of the
most cost effective and most qualitatively positive solutions to homelessness. Fourteen of the nineteen
studies reviewed for this research make a compelling case for supportive housing. This study is about
homelessness and the costs and benefits of providing supportive housing specifically in Metro Halifax.
The term “Metro Halifax” in this study refers generally to the geographic region of Halifax, while
“HRM” refers to the administration of the region. Although the results of examining the supportive
housing question may be predictable, a need has been identified for local information and data. This
study therefore aims to:



Contribute new ideas and information to the local discussion on the cost effectiveness of providing
supportive housing;
Begin compiling, in an overview fashion, local facts and costs associated with homelessness and
supportive housing in Metro Halifax. This serves as a basis for documenting gaps in services and
data;
Provide, through a selected literature review: comparative costs of supportive housing in other
Canadian and American cities; comparative cost of housing the homeless in other facilities, such as
shelters or hospitals; non-financial benefits of providing supportive housing to the homeless; and,
Dennis Culhane, taken from: Egan, Meg. (1997) “Three Degrees of Separation.” The Pennsylvania Gazette.
Retrieved March 2, 2006 from: http://www.upenn.edu/gazette/0297/homeless.html
1
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
6

1.1
Develop a simple tool that allows for broad comparison of financial and social effectiveness of
various approaches to reducing homelessness. It can also be used to identify cost effective
strategies for meeting specific homelessness needs.
Proposition
“ Doing nothing is not free….”2
It is cost effective and socially beneficial to invest in supportive housing for the
homeless in Metro Halifax using a “Housing First” approach, where the
supportive housing is permanent, offered immediately, with low entry demands.
The proposition is premised on these definitions:
Homelessness: The state of being without shelter. The absolutely homeless are those who do not have a
permanent place of their own to stay, including those who stay in emergency shelters, transitional
housing, or on the street and other public places. Households at risk of homelessness are those that
spend 50% or more of their gross income on shelter. 3
Supportive Housing: Public, private or non-profit housing with some form of support (income
assistance, counseling, medical care, life skills and employment training, etc) designed for people who
cannot live independently in the community. Providers receive funding for support services. The tenure
may be long term. There are four main models of supportive housing:
 Single-site residences with on-site services for families/individuals with special needs;
 Single-site residences with on-site or off-site services with varied levels of service needs;
 Scattered-site apartments with visiting services; and,
 Affordable housing developments with strong linkages to community-based services and referral
programs.4
Housing First: An approach to housing homeless individuals which holds the philosophy that before
someone can break the cycle of homelessness, a safe, comfortable home is necessary. Unlike
conventional “housing ready” programs, that require medication, abstinence from drugs or alcohol, and
participation in social services before receiving housing, Housing First places priority on providing
permanent housing immediately with few entry requirements. The services typically associated with
supportive housing are “unbundled” from the housing, they are still offered when required on an
individual basis.
Social Value Context: It is also important to note that the social value context (how society intuitively
responds to homelessness) for the above proposition has a wide range. One view states that a sense of
justice and societal responsibility prevails above all. The other argues that individuals need to take
responsibility for their situations while government intervention should be strategic if not limited. This
study would like to acknowledge that both views exist and may color how this kind of proposition is
received. The social value context that is assumed in this study is “somewhere in the middle”:
2
US Department of Housing and Urban Development, 2004. Strategies for Reducing Chronic Street
Homelessness
3 Halifax Regional Municipality, Planning and Development Services. 2005. Homelessness in HRM: A Portrait of
Streets and Shelters, Volume 2.
4 Task Force on Housing and Services for Families, 2003, as cited in Everyone has a Right to a Home: A
Community Needs Assessment of Harm Reduction Supports for the “Hard to House” in the HRM, Rehman,
Lourene.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
7
homelessness and poverty are seen as socially unacceptable, individuals need appropriate supports to
become self-sufficient, but ultimately any proposed solutions need to be sustainable in the long term.
Discovery: The Housing First approach brought a new realization to this research. The authors were
originally asked to investigate the cost effectiveness of supportive housing. Housing First was a
“discovery” of sorts that added new parameters to the supportive housing argument. It articulates that
for certain homeless individuals (the chronically homeless with mental illness and substance abuse
issues) simply providing supportive housing as part of a continuum of care may not be enough. Instead
the provision of housing needs to be permanent, should make minimal entry demands on clients, and
should be provided immediately, as opposed to a long progression through a continuum of recovery
stages where housing is earned. Housing First appears to make social and economic sense, where the
most vulnerable and costly segment of the homeless population is taken care of first, by providing safe,
affordable permanent housing, with supports when needed and few questions asked.
Admittedly there is some ambiguity in the literature whether the Housing First approach also includes
supportive housing. Some views present Housing First as simply an affordable housing program (if
aimed at homeless families for instance), others state that Housing First reverses the order in which
supports and housing are provided—the roof comes first, followed by individualized support services.
Some of this ambiguity is reflected in the data that has been collected and presented in the sections
below. Also, more data is presented for supportive housing than Housing First, partly due to
availability of information and partly due to the fact that the initial task was to examine supportive
housing costs only.
1.2
Methodology
The field of study that attempts to assess the social and economic costs and benefits of investing in
supportive housing is complex, and often limited by insufficient data5. The topic broached is
enormously complex. The scope of this research does not allow for a particularly probing and forensic
first hand research approach but rather aims to take a broad view that distills essential information to
further the argument for supportive housing and Housing First. The methodology is two-pronged: a
brief, targeted literature review and interviews with local providers of supportive housing and shelters.
The literature review focused on supportive housing cost benefit and cost analysis studies, with a
preference for Canadian figures (although American information proved to be more prevalent).
Ultimately American data is also relevant due to the fact that service delivery in the United States is
similar to that of Canada. Reports related specifically to the social benefits of providing supportive
housing were reviewed, as well as those focusing on the Housing First approach. The results of the
literature review are: an annotated bibliography (see Appendix B), and a series of trends and key
information that makes the case for supportive housing and the Housing First approach in Part 2 of this
study.
Nine supportive housing and shelter providers were interviewed in Metro Halifax. In total 13 providers
of supportive housing were identified in the area. Selection of providers was based on finding a sample
of facilities that serve a range of clients. Emergency shelter providers were included to illustrate
comparative local costs. The intent of this part was to compile a snapshot of existing supportive
housing services, including the supports they provide and their associated costs. Given the scope of this
research, an exhaustive series of interviews with all supportive housing providers was not possible nor
considered essential.
5
Berry, M. et al, in Counting the Cost of Homelessness: a Systematic Review of Cost Effectiveness and Cost
Benefit Studies of Homelessness, 2003
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
8
All service providers were contacted initially by telephone to solicit interest in participating in the
study. The key contact was usually the Executive Director of the organization. Subsequently a one to
two hour interview was agreed upon. In one case the organization’s accountant was also present, and in
another the house manager. From three of the organizations interviewed, information was obtained
about a range of supportive housing options offered by that organization (supportive apartments, group
homes, small options, developmental residence or residential care facility). Of the nine providers
interviewed, only one did not wish to share their financial information.
The key information sought in the interviews included: the type and range of supports provided, the
clients served, cost per person per day, funding sources, and perceived service gaps. The data gathered,
particularly regarding costs per person per day, came directly from the providers based on per diem
rates funded by the Department of Community Services. More detailed information about data
collection and results of the interviews is presented in Part 3 of this report.
The Nova Scotia Department of Community Services was also contacted to discuss the supportive
housing programs offered, particularly the capacity of existing facilities to meet the growing needs of a
diverse homeless population. Researchers were able to meet with a representative from the Housing
Division of the Department. However, representatives from the Persons with Disabilities Division,
which is responsible for providing supportive housing, were not accessible for an interview.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
9
2
Supporting the Proposition: Trends in Literature
2.1
Establishing the Context for Homelessness
A new profile of the “typical” homeless person is emerging. Historically, homeless people were
identified as middle-aged to older men who were frequently unemployed, often mentally ill,
handicapped, or an abuser of substances.6 Today homeless individuals come from diverse backgrounds.
Research has identified many more homeless women, married couples, younger people, members of
minority groups, and families with children.7 Recently, a model has emerged to identify the case
profiles of the homeless population as a way to understand their general needs.8 It identifies the
following three types of homeless individuals:
Transitionally homeless: The transitionally homeless population generally consists of people who enter
the shelter system for only one stay and for a short period of time. Those that are transitionally
homeless are displaced usually due to unforeseen circumstances such as a catastrophic event, or the
inability to pay rent due to loss of employment. They are likely to be younger and are the least likely
among the homeless to have mental health, substance abuse, or other medical problems. Over time, the
transitionally homeless are expected to account for the majority of people experiencing homelessness,
given their higher rate of turnover.
Episodically homeless: The episodically homeless are those who frequently go in and out of
homelessness. They are likely to be young, but often experience medical, mental health, unemployment
and substance abuse problems. The episodically homeless generally utilize the shelter system many
times for varying durations. Additionally, much of their time spent outside the shelter system is spent in
jails, hospitals, detoxification centers, or on the street. In most instances, the total population of the
episodically homeless is less than that of the transitionally homeless.
Chronically homeless: The chronically homeless are likely to be entrenched in the shelter system. They
are generally older, unemployed and suffer from substance abuse problems and/or disabilities.
Although the total population of the chronically homeless is usually less than the transitionally
homeless, the chronically homeless often accrue higher social costs due to the fact that they reside
within the shelter system for many years, or even a lifetime.9
Causes of Homelessness
Although the exact causes of homelessness may vary per individual, the literature concludes that there
are four general causes of homelessness:
Increased Poverty: Incidence and depth of poverty have increased due to changes in the labour market
and because of public policy changes such as restrictions on Employment Insurance eligibility and the
decrease in support of social assistance.
Culhane, Dennis; and Kuhn, Randall. (1999). “Applying Cluster Analysis to Test a Typology of Homelessness by
Pattern of Shelter Utilization: Results from the Analysis of Administrative Data.” American Journal of Community
Psychology Vol. 26, Issue 2
7 Shlay & Rossi, 1992; Sullivan & Damrosch, 1987 from: Applying Cluster Analysis to Test a Typology of
Homelessness by Pattern of Shelter Utilization: Results from the Analysis of Administrative Data
8 Lovell, Barrow, & Struening, 1984; Morse, 1986; Fischer & Breakey, 1986; Koegel, 1987; Snow & Anderson,
1987; Rossi, 1986; Hopper, 1989; Sosin et al., 1990; Jahiel, 1992 from: Applying Cluster Analysis to Test a
Typology of Homelessness by Pattern of Shelter Utilization: Results from the Analysis of Administrative Data
9 Culhane, Dennis; and Kuhn, Randall. (1999). “Applying Cluster Analysis to Test a Typology of Homelessness by
Pattern of Shelter Utilization: Results from the Analysis of Administrative Data.” American Journal of Community
Psychology Vol. 26, Issue 2
6
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
10
Lack of Affordable Housing: Provincial and Federal cuts have decreased the amount and availability of
affordable housing throughout Canada. The lack of funding and commitment has led to an inability to
provide adequate, appropriate, and affordable housing. People are spending a greater percentage of
their household income on housing costs to obtain substandard housing or are simply not able to
acquire accommodation.
Deinstitutionalization and Lack of Discharge Planning: Those with mental illness and addictions are
homeless partly due to deinstitutionalization without adequate community support and inadequate
discharge planning of hospitals and jails. Approximately one third of homeless individuals are mentally
The key information sought in the interviews included: the type and range of supports provided, the
clients served, cost per person per day, funding sources, and perceived service gaps. The data gathered,
particularly regarding costs per person per day, came directly from the providers based on per diem
rates funded by the Department of Community Services. ill10, and lack easy access to mental health
care.
Social Factors: Domestic violence, physical and sexual abuse, and alienation from friends and family
have increased the incidence of homelessness.11
Supportive Housing for the Homeless
In the 1980s, supportive housing began to be recognized as an effective housing strategy for people
with special needs. The first supportive housing projects were geared towards the elderly. In most
instances, one or more service components helped address the special needs of the clients who required
extra support to live independently.12
Supportive housing is a form of affordable housing with support services attached to help a client
perform daily living functions that may not otherwise be possible. People in supportive housing pay a
subsidized rate for their living accommodation. In most instances, the term “supportive,” refers to
community-based support services available to tenants to help them live as independently as possible
and retain their occupancy. Some examples of these services include: case management, physical and
mental health, substance use management and recovery support, job training, literacy and education,
youth and children’s programs, and money management.13
2.2
Housing First
Traditionally, homeless people begin to receive support in an emergency shelter, where they have
access to shelter, food, clothing, and government and non-profit services. Once they acquire financial
support, they may progress to transitional or supportive housing, and eventually into permanent
housing.
Golden, Anne. (1999). Report of the Mayor’s Homelessness Action Task Force: Taking Responsibility for
Homelessness: An Action Plan for Toronto.
11 Golden, Anne; Currie, William; Greaves, Elizabeth; and Latimer, John. (January 1999) Taking Responsibility for
Homelessness: An Action Plan for Toronto. Report of the Mayor’s Homelessness Action Task Force, City of
Toronto. P.V. Retrieved December 10, 2005 from: http://www.toronto.ca/pdf/homeless_action.pdf;
APA Policy Guide on Homelessness (2003) Denver, Colorado:
http://www.planning.org/affordablereader/policyguides/homelessness.htm
12 Technical Assistance Collaborative Inc. “Arlington Comprehensive Supportive Housing Plan.” Retrieved March
9, 2006 from: https://www.arlingtonva.us/Departments/HumanServices/pdf/supportiveHousingPlan.pdf
13 Corporation for Supportive Housing. (2005) “Voluntary Services” Retrieved February 28, 2006 from:
http://www.csh.org/index.cfm?fuseaction=Page.viewPage&pageID=3432#ph
10
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
11
Recently, however, governments in the United States have shifted their approach to “Housing First”,
where the homeless individual moves immediately from a shelter into independent, permanent
housing.14 This approach removes individuals from shelters and into long-term affordable housing
before the cycle of homelessness becomes permanent. The focus on immediate housing, places
individuals in a positive environment where they can begin to work on their problems and move
towards life-long, self-reliant changes.
Once they are stable and in permanent, affordable housing, individuals can regain their self-esteem and
start working on personal problems. The only requirements are those usually expected of by any
renter—pay the rent, do not destroy the property, and refrain from violence.15
The Housing First concept was pioneered ten years ago by Pathways to Housing, a program that
provides services for homeless adults with severe mental illness in New York. In 2005, the program
received a Gold Achievement Award by the American Psychiatric Association. As a testament to the
program’s effectiveness and demand, in 1993 Pathways to Housing hired five staff members and
served 50 clients. Twelve years later, there are seven other Housing First programs in New York and
two in Washington, D.C., serving and housing more than 550 clients.16
Since Pathways to Housing initiated the Housing First concept, national research centers such as
Beyond Shelter's Institute for Research, Training and Technical Assistance and the National Alliance to
End Homelessness' Housing First Network have been developing housing programs across the United
States. Today, there are more than fourteen organizations involved (see Appendix C). Many programs,
such as those in Columbus, San Diego, Seattle, and Los Angeles have been tremendously successful
with housing a variety of homelessness typologies: those with psychiatric disabilities and addiction
disorders, as well as those that are chronically homeless.17 Furthermore, a growing body of research
documents the ability of Housing First to keep even the most disabled homeless person housed.18
How the approach works
Consumer choice is key to Housing First. Empowerment helps clients identify their own needs,
recognize the choices they have, create options for themselves, and plan strategies for permanent
change in their lives. To enter the program, a preliminary assessment is conducted to evaluate the
individual’s circumstances and resources, range of needs required to stabilize them, their particular
strengths, and the level of individual/family functioning. Within a short period of time (usually 7-30
days) the person is housed in an affordable housing unit (which is integrated into the community). In
the affordable Housing First program, clients have access to individualized, home-based social support
services, to help them transition to stability.
APA (2005). “A Roof of One’s Own”.
Burt, Martha, John Hedderson, Janine Zweig, Mary Jo Ortiz, Laudan Aron-Turnham, and Sabrina M. Johnson.
January 2004. Strategies for Reducing Chronic Street Homelessness: Final Report. The Urban Institute. Retrieved
on March 5th, 2006 from www.huduser.org/Publications/PDF/ChronicStrtHomeless.pdf
16 Pathways to Housing. (October, 2005). Providing Housing First and Recovery Services for Homeless Adults
With Severe Mental Illness. Psychiatric Services, Vol. 56, 10. Retrieved on March 19th, 2006 from
http://ps.psychiatryonline.org
17 Burt, Martha, John Hedderson, Janine Zweig, Mary Jo Ortiz, Laudan Aron-Turnham, and Sabrina M. Johnson.
January 2004. Strategies for Reducing Chronic Street Homelessness: Final Report. The Urban Institute. Retrieved
on March 5th, 2006 from www.huduser.org/Publications/PDF/ChronicStrtHomeless.pdf. Pathways to Housing.
(October, 2005). Providing Housing First and Recovery Services for Homeless Adults With Severe Mental Illness.
Psychiatric Services, Vol. 56, 10. Retrieved on March 19 th, 2006 from http://ps.psychiatryonline.org
18 Anderson et al; 2000; Culhane, Metraux and Hadley, 2002; Martinez and Burt, 2003; Tsemberis and Eisenberg,
2000.
14
15
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
12
Figure 1. Housing First: Stages From Homelessness to Re-integration into the Community.
Source: Beyond Shelter: LA Programs - Ending & Preventing Family Homelessness.
How Effective is Housing First?
The Housing First model is relatively new; however, studies indicate that the program to-date has been
very effective. Alexa Whoriskey, from Pathways to Housing, tracked 57 clients between July 2002 and
February 2005, and found that after two years in Housing First, clients had a 92% reduction in
hospitalization days (from 327 to 27 days). A study conducted by Sam Tsemberis, found that 80% of
the participants in the study were able to maintain permanent housing at the end of the program
compared to 34% involved in “housing ready” programs. A third study, published in Psychiatric
Services (2000), followed 1,842 homeless with psychiatric disabilities in New York, examining their
housing retention rates between 1993 and 1997. Housing First models had an 88% success rate in
housing retention compared to 47% in other city programs.19 Thus, Housing First programs favoring
immediate housing and consumer choice deserve consideration as a viable alternative to standard care.
The National Alliance to End Homelessness has analyzed the effectiveness of Housing First programs
for families (see Table 1). All six programs showed a high degree of being successful in helping
families obtain and maintain permanent housing.
19
Pathways to Housing. (October, 2005). Providing Housing First and Recovery Services for Homeless Adults
With Severe Mental Illness. Psychiatric Services, Vol. 56, 10. Retrieved on March 19th, 2006 from
http://ps.psychiatryonline.org
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
13
Table 1: The Effectiveness of Various Housing First Programs.
Program
Result
Beyond Shelter (Los Angeles,CA)
Assessed 3 years after housing placement
 88% were still permanently housed
 66% were still in the same apartment those who had moved away were living in
similar or improved housing
 80% were paying their rent on time
Assessed 2 years after program entry
 85% were still permanently housed
 Those who did return to homelessness,
episodes were reduced from 30 to 10 days
Placed 359 individuals in permanent housing in
2002
 86% were still permanently housed in 2004
Placed 199 homeless families in permanent
housing between 2000-2002
 77% of all families served were housed in
permanent housing
Placed 128 families in permanent housing in 2002
 80% of families were in permanent housing
at time of exit
 families were moved out of shelter within
an average of 17 days
78% of families were placed in permanent housing
 70-80% moved into permanent housing
 of these, 70-80% remained permanently
housed for at least 1 yr
Rapid Exit Program
(Hennepin County, MN)
Home Start (Boston, MA)
Community Partnership for the
Prevention of Homelessness
(Washington, DC)
Family Housing Collaborative
(Columbus, OH)
Shelter to Independent Living
(Lancaster, PA)
Source: Beyond Shelter. The Problem: Ending & Preventing Family Homelessness.
These results have significant implications for interventions designed to reduce chronic homelessness.
Housing First models reduce the total number of annual hospitalization days per person, even when
compared to highly supportive programs such as housing ready.20 Higher housing retention rates are
also realized with individuals in Housing First. This suggests that intervention programs that give
priority to independent, affordable housing, remove program entry prerequisites, and value client
choice, are the most successful approaches to ending homelessness. Finally, studies to date demonstrate
that even the hard to house and those with severe psychiatric disabilities can remain stably housed and
live independently of shelter or dependent living housing programs. In the future, programs that favour
choice over restrictions and empowerment over compliance deserve serious consideration as effective,
cost saving, and human approaches to mitigating homelessness.
In 2004, a 10-year action plan for addressing homelessness in New York City was released. It identifies
Housing First, rather than “shelter first”, as the preferred long-term housing solution that shifts from
simply “managing” to “ending” homelessness.21 This Action Plan features well chosen, pertinent facts
and data about the homeless in New York that provide the basis for very specific initiatives and steps.
The argument for the Action Plan was based on a very detailed understanding of numbers, range of
needs and costs. The New York example can serve as a useful template for investigating homelessness
20
McCarroll, Christina (2002). Pathways to housing the homeless. The Christian Science Monitor Newspaper, May
01, 2002.
21 Uniting for Solutions Beyond Shelter, The Action Plan for New York City, 2004.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
14
in other cities, providing a reasonable outline of key information which can then be customized to the
particular context of another location.
Table 2: Data Related to Homelessness Gathered for New York Action Plan
A. Demographic Data





Number of individuals who are homeless, demographic breakdown, including
children.
Profile of street homeless population (largely individuals with mental illness and/or
substance abuse issues).
Where homeless families come from (which neighbourhoods/communities
experience disproportionate levels of family homelessness).
Last place of stay reported by single adults entering shelter.
Youth aging out of foster care who experienced homelessness.
B. Shelter and Facility Use







Number of individuals in shelters over the past 20 year.
Drop-in centre usage, monthly average, over three years.
Adults in shelter who had a jail stay.
Families with children spending a night at the emergency assistance unit during a
2 year period.
Estimated number of chronically homeless families with children using shelter over
the course of one year.
Estimated number of chronically homeless single adults and individuals in adult
couples using shelter over the course of one year.
Housing vacancies.
C. Cost and Budget Data







Amount spent on emergency shelters in last decade (4.6 billion).
Homeless families accessing public assistance (2 year period).
Single adult men and women receiving supplemental security income (SSI – social
assistance).
Number of chronically homeless and the resources they consume.
Department of housing budget growth.
Citywide prevention budget compared to DHS budget (estimate).
Cost effectiveness of supportive housing (compared to other sectors).
This type of data not only provides a detailed profile of the homeless and the services they utilize but
also highlights some of the key costs incurred. It provides a better sense of the homelessness “big
picture” and all of its aspects. How does Halifax compare? The same level of information is not
available. The snapshots of the homeless population gathered in shelters and on the streets over the past
two years in Metro Halifax begin to provide local data about who the homeless are22. Some of the data
collected through the snapshots reveals some similarities to the New York example, including the cost
effectiveness of supportive housing, and resources consumed by the local homeless population.
2.3
Economic Benefits of Providing Supportive Housing and Housing First
There is extensive literature in the United States on investing in supportive housing (Anderson, 1999;
Berry, Chamberlain, et al; 2003; Culhane, 2002, 2002; Eberle, 2001; Ehrlich, 2002; and Pomeroy,
2005). In Canada, Eberle (2001) and Pomeroy (2005), identified the cost savings of supportive housing.
22
Halifax Regional Municipality, 2003 & 2004.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
15
Homeless individuals in shelters or on the streets place a heavy burden on expensive health care, social
services, and the criminal justice system. Culhane calculated that in New York City, 95% of the
homeless use public health services, 76% use outpatient or inpatient services at the local public
hospital, 47% use substance treatment services, 65% use mental health services outside the hospital
system; and 40% receive health care while in the county jail.
Supportive housing can significantly reduce the use and cost of expensive public services. The
Corporation for Supportive Housing conducted a study in San Francisco, concluding that there were
dramatic decreases in public service usage after individuals were placed in supportive housing.
Emergency room visits dropped by 56%, hospital inpatient days decreased by 37%, drug and alcohol
treatment days decreased by 89%, and incarceration days fell to 44%.23 Culhane discovered that in New
York, individuals placed into supportive housing were associated with a reduction in service use of
$16,282 per housing unit per year. These cost savings were realized with a 72% reduction in public
health services, a 23% decline in shelter use, and a 5% reduction in incarceration. A study conduced on
the costs of homelessness in British Columbia had similar findings. It determined that society could
save between $8,000 and $12,000 dollars per year per person.24 Similarly, a comprehensive study
conducted by Culhane on Public Services Reductions Associated with Placement of Homeless Personal
with Severe Mental Illness in Supportive Housing, found a net reduction of $12,145 (US) per person
per year after homeless individuals with severe mental illness were placed in supportive housing. 25 A
study conducted by the Connecticut Supportive Housing Demonstration program, calculated a cost
savings of $5,454 per person per year on health care service alone, following placement in supportive
housing.26
The table below compiles costs associated with supportive housing and other service sectors from
various studies, using the following public service definitions:
Shelter: temporary housing available for the homeless over one night or several nights. Most
shelters include food, shelter, administration costs, clothing, and security.
Jail: locally operated correctional facilities. Most jail costs include food, administrative costs,
case management, and other prison services.
Prison: provincially operated correctional facilities. Includes costs such as operating and
administration, and other prison services.
Hospital: short term stay in patient institutions providing medical care by professionals,
including doctors and nurses.
Psychiatric Hospital: hospitals specializing in the treatment of patients with mental illness.
23
Harder and Company Community Research. (February, 2004). The Benefits of Supportive Housing: Changes in
Residents’ Use of Public Services. Prepared for The Corporation for Supportive Housing. Retrieved December
16th, 2005 from http://www.csh.org/index.cfm?fuseaction=Page.viewPage&pageID=3337
Eberle, Margaret, Deborah Kraus, Steve Pomeroy, David Hulchanski. (February, 2001). The Cost of
Homelessness in British Columbia. Province of British Columbia. Volume 3, Homelessness: Causes and Effects.
Retrieved on December 8th, 2005 from http://www.hvl.ihpr.ubc.ca/pdf/EberleCosts2001.pdf
24 Culhane, Dennis, Stephen Metraux, and Trevor Hadley. (May, 2001). The Impact of Supportive Housing for
Homeless People With Severe Mental Illness on the Utilization of the Public Health, Corrections, and Emergency
Shelter Systems: The New York – New York Initiative. Centre for Mental Health Policy and Services Research.
University of Pennsylvania. Retrieved on January 15th, 2006 from
http://www.fanniemaefoundation.org/programs/pdf/rep_culhane_prepub.pdf
25 Andersen, L. (1999). Connecticut Supportive Housing Demonstration Program: Program Evaluation Report.
University of Pennsylvania Health System, Department of Psychiatry Center for Mental Health Policy and Services
Research. Retrieved on January 20th, 2006 from www.dca.state.ga.us/housing/specialneeds/programs/downloads/
HomelessActionPlan /CSH_CTsupportHousing.PDF
26 Andersen, L. (1999). Connecticut Supportive Housing Demonstration Program: Program Evaluation Report.
University of Pennsylvania Health System, Department of Psychiatry Center for Mental Health Policy and Services
Research. Retrieved on January 20th, 2006 from www.dca.state.ga.us/housing/specialneeds/programs/downloads/
HomelessActionPlan /CSH_CTsupportHousing.PDF
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
16
Supportive Housing: housing that combines building features and personal services to enable
people to remain living in the community as long as they are able and choose to do so.
Operating costs include housing, utilities, case management, employment services, and staffing
and administrative services. Table 3 compares the costs of various service sectors.
Table 3. Comparative Costs of Various Service Sectors by City (costs per person per day $)
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
17
Culhane’s study (2001) shows that not all homeless people use public services on a daily basis. His
study follows over 4,000 homeless individuals, over a 2-year period (one year in a shelter, followed by
one year in supportive housing). His research concluded that individuals placed in supportive housing
significantly reduced their use of public services (Table 4).
Table 4: Service Use by a Homeless Individual in a Shelter Compared to
a Formerly Homeless Person in Supportive Housing.
Services
Average
Use
by
Homeless (days/yr)
5
4.65
28.65
8.25
Source: Culhane, 2001.
Jail
Prison
Psychiatric
Hospital
Average Use by Person
in Supportive Housing
(days/yr)
3
1.2
12.5
1.65
Housing First Cost Savings
Housing First is emerging as a practical, cost effective means to ending and preventing homelessness.
For example, in the Housing First programs for families, analyzed by the National Alliance to End
Homelessness, the client pays 30% of their income towards rent, while the program helps supplement
their food and clothing costs with a monthly or weekly stipend. The program realizes large cost savings
through service provision, because it coordinates and links up with existing systems, rather than
creating new ones. In the United States, most of the agency’s funding is from the government.
The cost of Housing First varies depending on the needs of individuals or families in the program. The
literature indicates that Housing First is equal if not cheaper than conventional treatment programs. 27
Culhane (2001), calculated that a homeless person with mental illness living on the street in New York
costs the government approximately $41,000 a year for shelter, social and health services. A shelter bed
alone costs between $27,000 and $35,000 per year. The Housing First program costs $22,000 per client
per year for both housing and treatment.28
The National Alliance to End Homelessness calculates that Housing First costs even less.29 The cost
per participating family or individual varies because more expensive programs provide higher levels of
direct financial assistance and longer periods of case management services. Even so, the most
expensive program costs the same or less to deliver than it costs to house a family in an emergency
shelter for four months.30 The Community Care Grants Program in Washington, DC calculates that it
27
Pathways to Housing. (October, 2005). Providing Housing First and Recovery Services for Homeless Adults
With Severe Mental Illness. Psychiatric Services, Vol. 56, 10. Retrieved on March 19th, 2006 from
http://ps.psychiatryonline.org
28 Pathways to Housing. (October, 2005). Providing Housing First and Recovery Services for Homeless Adults
With Severe Mental Illness. Psychiatric Services, Vol. 56, 10. Retrieved on March 19th, 2006 from
http://ps.psychiatryonline.org
29 National Alliance to End Homelessness (need REF)
30 The cost of providing shelter to families varies by location. In Washington, DC, the cost of the Community
Partnership’s Community Care Grant program is “about $7,186 for every family successfully housed, which is
equivalent to the cost of 116 days in an emergency shelter (where the average stay exceeds six months).” The
Center for the Study of Social Policy,
“Homelessness: An Assessment of the District of Columbia’s Community Care Grant Program,” 2003.
http://www.cssp.org
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
18
costs on average $7,186 per year to place a family in permanent, affordable housing, equivalent to the
cost of placing a person in emergency shelter for 116 days or four months. 31
2.4
Social Benefits of Providing Supportive Housing and Housing First
Much of this report is focused on the fiscal benefits of reducing homelessness through the provision of
supportive housing (measured in reduced hospitalizations or jail sentences). By also including the
social benefits of providing supportive housing, the discussion is, hopefully, raised to another level of
understanding where the real, human complexities of homelessness are factored in.
Existing studies have consistently shown that when individuals are provided with adequate housing and
necessary supports, there are clear cost benefits as well as an increased likelihood of continuing to live
in stable housing, staying off the streets, and out of shelters and psychiatric institutions.32 Much less
attention, however, has been given to quality of life outcomes.33 One study (Nelson et al, 2005) takes a
narrative approach to evaluating the quality of life of people with serious mental illness, after they
entered supportive housing compared with their experiences before residing in supportive housing.
Through a series of personal interviews, the study found that overall participants felt more independent,
had greater feelings of well being and had a better outlook for the future. Some participants attributed
staying out of jail and controlling their addictions to having stable, supportive housing. They were able
to develop positive relationships with other residents and staff, who were often referred to as helpful
and friendly. Having stable housing, food, and clothing contributed to feelings of safety, and provided
the impetus for more employment opportunities. Finally participants felt more integrated into
community life, with opportunities for recreation and more personally fulfilling and meaningful
activities such as volunteering.
A study conducted by Sam Tsemberis et al34, examines the effects of a Housing First program for
homeless mentally ill individuals. The Housing First participants were compared to a control group in a
Continuum of Care program, where clients are expected to be “housing ready”. This means having to
comply with sobriety and psychiatric treatment before receiving permanent supportive housing. The
results found that participants in the Housing First program had greater perceived choice and control in
treatment programs, which were made available but not mandatory. They also had an 80% housing
retention rate, which is considered very significant for a group of formerly homeless people with
serious mental illness. Both groups showed no differences in psychiatric symptoms and the same levels
of drug and alcohol use but Continuum of Care group reported higher use of substance abuse treatment
programs, which is predictable since treatment is required in that program. What is interesting,
however, is the same level of substance use in both groups despite much lower rates of using treatment
programs (at a lower associated cost) in the Housing First model. The study concludes “providing
Housing First may motivate consumers to address their addictions to keep their housing, so that
providing housing before treatment, may better initiate and sustain the recovery process”.
Other reports indicate that negative effects increase the longer homelessness continues, including more
health problems (possibly from living in places not meant for habitation) and increased mental health
Nkomo, Lavonne. (June 20, 2003). An Assessment of the District of Columbia’s Community Care Grants
Program. Centre for the Study of Social Policy.
32Nelson, Geoffrey; Clarke, Juanne; Febbraro, Angela; Hatzipantelis, Maria. “A Narrative Approach to the
Evaluation of Supportive Housing: Stories of Homeless People Who Have Experienced Serious Mental Illness”.
Psychiatric Journal; Fall 2005; 29,2; ProQuest Medical Library.
33 Nelson et al.
34 Tsemberis, Sam, PhD; Gulcur, Leyla PhD; Nakae, Maria BA. “Housing First, Consumer Choice, and Harm
Reduction for Homeless Individuals with a Dual Diagnosis”., PhD et al, American Journal of Public Health, April
2004; Vol. 94, No.4.
31
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
19
symptoms such as anxiety, and depression.35 With stabilized living conditions and constant exposure to
opportunities for better health and recovery, those in permanent supportive housing have a higher
chance of leading productive and more independent lifestyles.36
In conclusion, the literature review clearly shows that there are measurable cost savings when homeless
individuals are diverted from the shelter system to supportive housing. The savings can range from
$16,000 to $12,000 (USD) per person per year. Concurrently there is a significant reduction in service
use by the previously homeless individuals placed in supportive housing and overall improvement in
the quality of their life. Although less data is available for the Housing First approach, similar social
and economic benefits are inferred. In addition there are higher retention rates of permanent housing in
the Housing First approach as well as similar reductions in drug and alcohol use, but at a reduced cost
to society.
The study now proceeds to look at the Metro Halifax situation in some detail.
US Department of Housing and Urban Development. (2005). “Strategies for Preventing Homelessness.”
Retrieved March 8, 2006 from: http://www.urban.org/UploadedPDF/1000874_preventing_homelessness.pdf
36 Golden, Anne; Currie, William; Greaves, Elizabeth; and Latimer, John. (1999) Taking Responsibility for
Homelessness: An Action Plan for Toronto. Report of the Mayor’s Homelessness Action Task Force, City of
Toronto. Retrieved December 10, 2005 from: http://www.toronto.ca/pdf/homeless_action.pdf; and Tsemberis, Sam;
and Eisenberg, Ronda. (2000). “Pathways to Housing: Supportive Housing for Street-Dwelling Homeless
Individuals with Psychiatric Disabilities.” Psychiatric Services. Volume 51. Retrieved March 2, 2006 from:
http://www.psychservices.psychiatryonline.org/cgi/content/full/51/4/487; and Andersen, L. (1999). Connecticut
Supportive Housing Demonstration Program: Program Evaluation Report. University of Pennsylvania Health
System, Department of Psychiatry Center for Mental Health Policy and Services Research. Retrieved on January
20th, 2006 from www.dca.state.ga.us/housing/specialneeds/programs/downloads/ HomelessActionPlan
/CSH_CTsupportHousing.PDF
35
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
20
3
Supportive Housing in Metro Halifax: Local Profile
3.1
Who is Homeless in Metro Halifax?
Through the Portrait of Streets and Shelters studies conducted by HRM in 2003 and 2004, there is a
greater understanding of the nature and extent of homelessness in Metro Halifax. The homeless
population has an average age of 35, with about one-third under age 24 (34%). Homeless males
outnumber females at a 2:1 ratio. A vast majority (94%) of respondents were single; a small proportion
belonged to some sort of family unit, whether as a family or a couple. Visible minorities are
consistently over-represented in the homeless population, with about 16% of people falling into this
category. About half of the homeless people surveyed rely on some form of Government assistance (in
the form of employment insurance, pension or disability) as their sole source of income. A quarter of
respondents cited no source of income at all, while less than ten percent earned income through
working.
An area of concern is that one-fifth (20%) of survey respondents have spent more than six months, and
in some cases more than a year, without a permanent home. These individuals rely on friends,
temporary housing and emergency shelters to provide a safe place to sleep. Within the total population
of the region, 25,180 households are considered to be in core need of housing, spending more than 30%
of their income on housing. There are many in this group at serious risk of becoming homeless because
they spend more than half of their gross income on housing.
The homeless population in Metro Halifax has specific needs beyond affordable housing. Many
respondents reported one or more health problems; one-third indicated they suffered from an addiction,
another 20% had mental illness issues, and 4% were faced with a physical disability. Five percent
reported dual issues with mental health and addictions. While many of these individuals were
managing to gain access to some health care or mental health services, few were able to find stable
housing. It is this subset that requires special attention and care, as the hard to house population, in
terms of the services and facilities that should be provided.
Inevitably the characteristics of the homeless population may change over time. Subsequently on-going
monitoring and gathering of data is important and necessary. Now that the Portrait of Streets and
Shelters has been established as a useful benchmarking tool, there is an urgent need to continue, on a
regular basis, to gather data that accurately portrays the profile of the local homeless individual.
3.2
Service Providers Interview Outcomes and Observations
As previously noted in the methodology section of this report, nine supportive housing and shelter
providers were interviewed in Metro Halifax. In total 13 providers of supportive housing were
identified in Metro Halifax. Most of the organizations listed below operate more than one facility and
target various stages of recovery from homelessness.
1. Alice Housing
2. Metro Community Housing Association
3. Metro Non-Profit Housing Association
4. Phoenix House
5. Adsum Court
6. Regional Residential Services Society
7. Nova Scotia Department of Community Services
8. Homebridge Youth Society
9. Salvation Army
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
21
10.
11.
12.
13.
Saint Leonard’s Society
Lesbian, Gay and Bi-Sexual Youth Project
MISA
Tawaak Housing Association.
Table 5 below compiles the findings of the interviews. Direct reference to organizations has been
removed in order to provide a level of anonymity, requested by some of the service providers. The
information below further expands on the findings and provides some observations and discussion.
Table 5: Supportive Housing Costs, Shelters and Funding Sources in Metro Halifax
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
22
Table 5 (continued)
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
23
Type and range of supports provided
In addition to the safety of a roof and bed, the most common form of services in virtually all of the
supportive housing in Metro Halifax is some degree of case management, referrals to appropriate
health, financial or training staff, life skills programs and frequently some form of rental subsidy.
Observation: All services are client based and highly individualized, which is a positive characteristic
as it responds to a large range of needs, but at the same time this poses some difficulty in drawing
parallels among the different facilities and associating comparable costs.
Supported Apartments: Housing which is geared to the most independent residents, singles or families,
and tends to be longer term (in one case up to three years) or permanent. The apartments can be
operated by not-for-profit agencies or the public sector (public housing for seniors). Meals are not often
included although there may at times be access to communal meals and arrangements for more frequent
access to the food bank. Services associated with the apartments can be on or off site and include case
management and referrals, day programs (sometimes mandatory) such as life skills, parenting, and
financial management.
Group Homes: Supportive housing for a group of four to eight individuals, with similar needs. The
level of associated support varies tremendously. All include meals and have at least one on-site staff
person. The role of this person can range from helpful roommate who aids in preparing meals,
organizing activities and is able to sleep at night, to staff who need to remain awake during night shifts
and are in constant demand because of the unique needs of the residents. The ratio of staff to residents
increases as resident needs intensify. For instance the group home for youth with serious behavioral
issues maintains a 3 staff to 4 youth ratio. The group homes are typically connected to case
management support and various day programs.
Developmental Homes: Functions like a group home for individuals with intellectual disabilities and
more intense needs.
Small Options: Refers to the name given to a program funded by the Nova Scotia Department of
Community Services and operated by non-profit organizations (two of them were interviewed for this
study). Care is provided for up to three individuals with disabilities in a house or rented unit on a fulltime basis. The level of care provided varies widely, depending on the needs of the clients. Meals, case
management, referrals and day programs are part of the support.
Residential Care Facility: Supportive housing for adults with mental illness that is institutional in
nature, similar to a large boarding home. Many of the clients in this particular case are older and not
expected to move on. The rooms are shared, meals are provided, laundry is taken care of and
medication is monitored. There is some access to day programs and outside activities are encouraged
but not funded.
Emergency Shelter: The terms “supportive housing” as opposed to “emergency shelter” may infer that
few if any support services are associated with the shelters. In reality a number of services, in addition
to a bed, are offered in the emergency shelters, the difference being intensity of support and duration.
Shelters are intended to be short term (30 days) so the case management and type of referrals available
reflect this. There are some day programs available, including life skills, financial management (trustee
program in one case), health counseling, some meals (or referral to local church meals or soup kitchen).
The emergency center for troubled youth, departs from the traditional shelter model, and operates much
more like a crisis center, with very intense support, intervention teams, structured programming and
even a classroom and teacher on site for youth unable to remain in the public school system.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
24
Clients served
The research targets a range of client types: single men and women, women with children, and youth,
all facing a spectrum of challenges; mental illness, domestic violence, addiction. Purposefully the study
includes a client type that may not typically be associated with homelessness studies: individuals with
intellectual disability (a permanent disability as opposed to mental illness, which can be episodic and
may be treatable). Interestingly the service provider responsible for persons with intellectual disability,
when originally contacted, felt that a study focused on homelessness did not necessarily pertain to this
group of clients because they are not usually affected by homelessness. Their entry point into the
supportive housing system is typically from a home environment where the care givers (aging parents,
relatives) are no longer able to provide care but had made arrangements for the organization to step in
when necessary. Clients can be placed on a waiting list, sometimes for years, until they need the
service. This group was included in the study for comparison, to illustrate the approach and costs.
Observation: Perhaps what is worth noting in the persons with disabilities case is that the supportive
housing system put in place has in large measure been successful (if success is measured by how many
end up homeless). And, it would appear, that a particular standard has been established for taking
responsibility of the mentally disabled in our society, one that states that homelessness among this
group of individuals is unacceptable.
Cost per person per day
The costs obtained for the study came directly from the supportive housing providers. The facilities
funded entirely by the Department of Community Services (DCS), were easily able to provide a cost
based on the per diem rate they received for a particular type of supportive housing. The organizations
with more diverse funding sources and operating a number of different facilities, found it more difficult
to provide a per diem rate. In those cases, their total operating budget was divided by the number of
clients to obtain an average cost.
Observation: The range of costs is enormous, reflecting the wide range of supports that can be offered.
The most expensive aspect of supportive housing is not the housing itself but the support associated
with it and the number of trained staff required to operate it.
The lowest cost obtained in the interviews, $11 per day for supported apartments, is subsidized by
some of the other programs operated by that organization, which could not easily be figured into the
estimate. Other supported apartment costs range from $23 to $44, while small options and group homes
typically cost $100 to $200 for middle range services and $250 to $560 for very high needs residents,
such as individuals with both intellectual and physical disabilities or youth with intense emotional and
behavioral difficulties.
Observation: It would appear that facilities totally funded by the provincial government are more
costly, however these facilities are geared toward individuals with very high needs therefore the costs
are understandably higher. The true cost per person of supportive housing in some instances is not
totally revealed, since some living expenses such as travel or prescription drugs are billed to
Community Services per individual over and above the per diem rate. In the case of troubled youth,
additional costs are incurred for off-site psychiatrists and assigned social workers, raising further the
cost per person.
Funding sources
This study also probed the source of funding for each of the organizations with the aim of
understanding the burden shouldered by the agencies themselves and the level of commitment from the
provincial government. Of the eight providers interviewed, the province funds three at 41% and less,
with the balance of the budget being supplemented by fundraising, grants and rent. It should be noted
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
25
also, that often rent paid by residents is the shelter allowance from their income assistance, therefore
indirectly the facility is receiving additional provincial funding. The remaining five providers receive
the majority of their funding from DCS, ranging from 90% to 100%, either in the form of block
funding or per diems for occupied beds, or a combination.
Observation: Interestingly some of the providers who officially are 100% funded by DCS, have
recently begun fundraising to supplement their budgets. The raised funds are allocated for additional
day programs as well as training for staff. Some of the providers felt that in order to responsibly and
fully provide appropriate care, day programs and staff training need to be better funded.
3.3
Perceived Service Gaps
All of the providers in the interviews were asked whether there are any gaps in the services they are
able to provide or in the continuum of care available to the homeless or those at risk. The information
below is admittedly anecdotal, collected through a loosely structured discussion with providers.
However, upon reflection and consolidation of information, a number of recurring concerns and trends
emerged under the following themes:
Day Programs
All three emergency shelter providers (and several of the supportive housing providers) would like to
provide better and more day programming, including health education, parenting classes, anger
management, financial planning, job searching and other basic life skills which many of the clients lack
upon arrival to the shelters. When asked if these services are better provided as part of supportive
housing, the answer was that ideally they should be made available in both places: in the shelters
because individuals need these skills immediately to make better, educated decisions and later once in
supportive housing, to reinforce and further develop what they learned already. Day programs for the
intellectually disabled and mentally ill are seen as imperative to their development and to leading a
fuller life, allowing individuals to be integrated in their communities. The province, according to the
providers, does not adequately fund this type of programming.
Prevention
Two providers of supportive housing for the youth interviewed felt more investment should be made in
preventative measures, that is to deter individuals from entering the homelessness cycle. In the case of
youth, this translates to providing access to counselors and outreach workers in the community and in
high schools, to deal with issues such as family violence, teen pregnancy or addiction. Another aspect
of the preventative model advocated by the providers is education, ensuring that youth stay in school, is
known to reduce the likelihood of experiencing homelessness.
Affordable Housing
Virtually all felt that the absence of enough affordable, safe housing in the Halifax Region was an
enormous gap in the continuum of care available to the homeless or those at risk. Lack of affordable
housing affects those who have successfully transitioned through treatment programs or job training,
and do not require a supportive housing setting any longer, but simply need safe and affordable
housing. These individuals end up staying in supportive housing longer than necessary, preventing
more needy clients from accessing the unit, or may return to a shelter or the street if they cannot find
affordable housing. The lack of affordable housing not only affects but creates the group known as “at
risk of homelessness” (those who pay 50% or more of their income for shelter.)
Staffing
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
26
In several cases, due to lack of funding, individuals with minimal training are filling positions best
filled by social workers. Some organizations are careful not to call their services counseling because
the properly trained people could not be hired. In the worst case scenario, the implications can be life or
death, if for instance a suicidal resident cannot be dealt with appropriately due to a lack of properly
trained staff. Another aspect of staffing that providers are concerned about is their inability to provide
regular training for existing staff due to limited funds. Most of the providers who are entirely funded by
DCS, felt that DCS does not consider staff training a priority –in a field where the appropriate
knowledge and experience can make a difference between someone returning to the streets or
committing to a process of recovery.
Outreach
Outreach services in the community, were identified as lacking by both, providers of shelters and
providers of supportive housing. Shelter providers felt that better outreach programs would first, enable
them to assist clients still in the shelter access the services they need, such as keeping appointments or
maintaining their recovery programs. In terms of discharged clients, outreach staff could follow up and
maintain contact, help individuals access the next stage of housing and prevent them from reentering
the shelter system. At the moment, once an individual leaves a shelter, staff has limited knowledge of
their next steps, until the moment they return to the shelter (one provider stated that approximately 25%
of their clients return on a regular basis, another felt their repeat clients constitute over 30%). What
outreach work would also provide is much needed data on the status and progress of these clients.
Mental Health Services
One of the most frequently mentioned service gaps was related to mental health. Most of the providers
felt that access to mental health professionals and appropriate treatment is inadequate, citing long
waiting lists for treatment, unavailable beds in emergency situations and a lack of information about
clients upon discharge from institutions. In addition, it was felt that the absence of discharge planning
often results in individuals being released into the emergency shelter system – a system that does not
have the capacity to properly care for individuals who may be a danger to themselves and others, and
often have special medical and rehabilitative needs. “The mental health system is in a crisis” declared
one shelter provider when describing how a suicidal client, taken to emergency, was released back to
the shelter within four hours. Another supportive housing provider identified the need for a child
counselor on their premises to treat children surviving family violence. Otherwise, it was stated, these
children wait for one year before seeing a mental health professional.
Rigid Funding Programs
Funding programs operated by the Department of Community Services are sometimes too rigid and
lack flexibility to respond to unpredictable client situations, felt some of the providers. For instance
limited possibilities for housing choices make it difficult to place a couple who is intellectually
disabled. Some funding arrangements seem to have a built-in disincentive to not progress into the next
level of care. If a client for some reason needs to return to the supportive housing situation, often it is
very difficult or impossible within a reasonable time frame.
Waiting Lists and Capacity
Surprisingly, none of the service providers are functioning over capacity nor do they appear to be faced
with long waiting lists. The organizations funded entirely by the Department of Community Services
receive referrals from the Department and are not aware how extensive, if at all, the waiting lists are.
At this point it is difficult to discern whether or not existing services are adequate in terms of the
numbers of homeless. It is more apparent, however, that the diversity of needs among the homeless is
not being met by current organizations. For instance, according to providers, there is a substantial need
for supportive housing for families with children, youth with intense behavioral issues, older
individuals, youth, and those with mental health and addiction issues.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
27
3.4
Supportive Housing Cost Effectiveness: Metro Halifax Application
Having looked at the local profile of supportive housing in Metro Halifax, the next step in the study is
to determine its cost effectiveness by using data that is available locally, and where not available,
applying data from the literature search. In the following tables, a cost savings comparison was
designed to determine the approximate value of investing in supportive housing in Metro Halifax.
Costs for six major public services typically accessed by homeless individuals: shelter, jail, prison,
hospital, psychiatric hospital, and supportive housing – were calculated per person per day. These six
public service categories were derived from the Lewin Study, Costs of Servicing Homeless Individuals
in 9 Cities.
The Metro Halifax costs (Table 6) for supportive housing and shelter were obtained from interviews
with local service providers, taking an average of the costs of providing each service per person per
day. Remaining costs are cited from literature: jail and hospital costs from Dodds & Colman, 1999, The
Cost of Crime in Nova Scotia; prison and psychiatric hospital costs from Pomeroy, 2005, The Cost of
Homelessness: Analysis of Alternate Responses in Four Canadian Cities.
Table 6: Public Facility Costs per Person per Day in Metro Halifax
Type
of
Facility
Public
Supportive housing
Cost
per
person
per
day (CDN)
$39.50
Shelter
$58.00
Jail
$121.00
Prison
$275.00
Psychiatric hospital
$210.50
Hospital
$662.00
Sources: Dodds and Colman(1999), Pomeroy (2005),
locally gathered data through interviews with service
providers.
The frequency of service usage (days per year) was derived from Culhane’s study in New York (Table
7) and applied to Metro Halifax. This study is the only previous work with sufficiently large sample
size and study period to provide data on the average number of days each type of public service was
used by both homeless individuals and those in supportive housing.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
28
Table 7: Public Facility Use in Metro Halifax, Days Per Person / Year
Type of Public Facility
Homeless
Supportive housing
N/A
Supportive
Housing
336.75
Shelter
318.45
9.90
Jail
5.00
3.00
Prison
4.65
1.20
Psychiatric hospital
28.65
12.50
Hospital
8.25
1.65
Source: Culhane et al (2001).
Based on the average number of days homeless people use public services as presented above, the
average costs of providing these services in Metro Halifax were used to calculate the cost per homeless
person per year in the municipality. The figures were annualized for comparison purposes to present a
picture of the entire year, and to account for a continuum of users over a 365 day period. By isolating
individual service categories, the annual cost savings for a person in supportive housing compared to a
homeless person become apparent. (see Figure 2 below).
Figure 2. Comparative Costs of Public Facility Use in Metro Halifax
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
29
A cost savings comparison between homelessness and supportive housing for Metro Halifax is
provided in Figure 3. The graph illustrates that the total cost of providing services is much lower for
people in supportive housing facilities, including the cost of providing the support. The annual costs
associated with the average homeless person is drastically reduced through the provision of supportive
housing. The cost of all other services combined accounts for less than one-third (29.2%) of the total
cost associated with a person in supportive housing. In Metro Halifax a cost savings of 41% per
homeless person could be achieved by investing in supportive housing.
Figure 3. Comparison of Total Annual Costs of Public Facilities Per Person in Metro Halifax.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
30
4
Supportive Housing: Making the Decision
While any homelessness strategy needs to deal with prevention and crisis management, in the end it is
about providing appropriate housing and supports. This is a long-term view. This stance provides
obvious social benefits, such as more productive members of society and improved quality of life for
the homeless individual, but is also cost effective in that it reduces spending in the justice and health
systems.
The final part of this study provides a tool, which compares the cost effectiveness and benefits of
various homelessness strategies. In order for the tool to be effective it relies on accurate data of who the
local homeless are, what services already exist, what the capacity of those services is, what needs are
currently unmet and the current cost of services. A series of local facts, figures and information is
required in order to make the investment decision knowingly.
This tool is a first step. It is based on data gathered locally from service providers as well as
information gathered from relevant studies. It consists of three parts, intended to work together:
4. Comparative costs of housing approaches: a table that provides a way of assessing and comparing
costs for emergency shelters, supportive housing and Housing First approaches.
5. Other costs of providing various housing approaches: a table that provides a way of assessing and
comparing costs for hospital, psychiatric hospital, jail and prison, incurred by someone in a shelter,
supportive housing, or in a Housing First model.
6. Social benefits of providing various housing approaches: briefly outlines key social benefits
associated with each housing approach, to serve as a qualitative complement to the financial data.
The tool provides a way of organizing costs and benefits of various broad strategies. In a general way it
can be used to demonstrate the costs of homelessness and the benefits of investing in supportive
housing or Housing First. In a more particular sense it is a way of gauging the costs and benefits of
investing in shelter, supportive housing or Housing First that meet the needs of specific sectors of the
homeless population. It is understood that everyone is an individual, there is no average homeless
person. It is also clear that there are different categories (needs), degrees of support, and housing
configurations. The tool is illustrated below so that reasonable comparisons can be made.
To make the case for investment in either strategy it is essential to identify the needs. The needs will
determine specific costs and supports required and benefits achievable. In the local context, it is useful
to identify the need in terms of a population group, for instance men with dual diagnosis (as opposed to
identifying the need for a particular facility) and the intervention and support that is required.
Understanding who is homeless in Metro Halifax, their profile and their needs is the first, fundamental
step on the road of providing appropriate supportive housing solutions. Simply stated there must be an
understanding of who is homeless and what they need, what already exists to help them and what else
should be provided.
The two Portrait snapshot studies of homeless individuals in Metro Halifax (HRM, 2004, 2005)
effectively paint the profile of local homeless individuals, providing benchmark data about
demographics, use of emergency facilities, health issues and causes of homelessness, among other
pertinent information. A range of issues exhibited by homeless people can be extrapolated for HRM
from this study, using data for causes of homelessness and self-reported health status. One possible
“cut” through that information is provided in Table 8 below. Other, more detailed, ranges are also
possible, particularly if data from existing supportive housing providers can be incorporated (when and
if it exists).
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
31
The first Portrait study also identifies the stock of social housing in HRM: 4,400 public housing units,
1,300 co-op units, 200 available beds in the emergency shelter system and 3,215 beds in supervised
residential facilities for mentally disabled adults operated by the Nova Scotia Department of
Community Services. For the purpose of this study a more detailed breakdown would be useful, one
that clearly describes who is the targeted client by each of the facilities.
The next step in determining which needs are being addressed is to match the identified issues with
existing facilities. Although this table (Table 8) is simplistic and only intended to provide a snapshot
understanding of who is already “taken care of” by existing facilities, it does provide information that
does not currently exist about supportive housing and who it targets in Metro Halifax.
Limitations of this approach include the absence of actual counts for both, the capacity or bed/unit
count provided by the facility and the number of clients who need that particular facility and the type of
supports if offers. This is one information gap that could be addressed in future research. Although this
study did attempt to contact the Department of Community Services, Persons with Disabilities
Division, to obtain information about waiting lists for supportive housing and the existing capacity to
meet those needs, that information was not accessible to the researchers.
Table 8: Clients Served by Existing Metro Halifax Supportive Housing Facilities (excludes
transition housing)
Note: checkmark indicates that a supportive housing facility is available to serve that particular client typology. Multiple
checkmarks indicate the number of facilities in Metro Halifax.
4.1
Understanding the Tool
It is important to view the following three tables (9 to 11) as parts of the same tool, which together
provide a more telling picture of the real costs and benefits of providing various housing approaches for
homeless individuals in Metro Halifax. Tables 12 and 13 are applications of Tables 10 and 11
respectively in the local context. The flow chart below (Figure 4) is intended as an overview and a
“legend” to the tool. It illustrates the relationship between the main information elements and how they
build to make the case for a particular housing approach.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
32
Figure 4. Tool Overview
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
33
4.2
Housing Approaches in Metro Halifax: Comparing the Costs
Table 9 explains the parameters for assessing the costs of providing shelters, supportive housing or
Housing First options. Table 12 further below illustrates the application of these parameters in the
Metro Halifax context.
Table 9: Comparative Costs of Housing Approaches
Table 10 below outlines the public facilities typically accessed by homeless individuals while living in
a shelter, supportive housing or Housing First situation. Daily costs for these facilities are provided as
well as the average yearly use of each facility depending on the housing situation. This table provides
the data for the Metro Halifax calculations presented later in Table 13.
Table 10. Costs and Use of Various Housing Approaches
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
34
Table 11 below summarizes some of the social benefits associated with living in each of the housing
situations: shelter, supportive housing and Housing First. These benefits have been compiled from the
literature review and abbreviated in order to provide a quick at-a-glance reference. The table is
intended to be used in conjunction with tables 9 and 10, as a qualitative description of each housing
option that goes beyond the costs. The social benefits articulate the quality of life that is achievable for
individuals, the relationship advantages as well as overall benefits to society. Incorporating a
qualitative aspect in this tool may not be as straight forward as comparing specific cost figures among
the different housing options, nevertheless it is important as it provides a more accurate picture of the
real cost and benefits of addressing homelessness.
Table 11: Social Benefits of Providing Various Housing Approaches
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
35
Table 11 (continued)
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
36
4.3
Metro Halifax Examples
Tables 12 and 13 illustrate the application of the tool to the Metro Halifax context. The data is a
mixture of locally obtained figures and applied figures from the literature review. The specific
relationships among the different housing approaches and public facilities have also been applied to the
Halifax area. This is a broad and general template based on the frequency of use of each facility by the
homeless individual.
Table 12: Comparative Costs of Housing Approaches in Metro Halifax
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
37
Table 13: Costs and Use of Various Housing Approaches in Metro Halifax
The example calculations provided in the above tables illustrate the possible local cost savings when a
homeless individual using shelter facilities is provided with supportive housing or Housing First
options. Supportive housing, in this illustration, costs 57% less than keeping someone in a shelter,
while Housing First is very similar at 58% less. As noted in Table 13, specific cost figures and service
reductions for Housing First are difficult to obtain and those that do exist vary considerably based on
program details. One possible reason for the limited data is the fact that Housing First is still a
relatively new model and requires more in-depth study and analysis. Nevertheless, relevant studies
state the cost to be at least the same as supportive housing or less, given that it eliminates or reduces
some transitional steps in the continuum of care approach. More importantly some of the social benefits
are greater in the Housing First approach, namely choice in treatment, better retention of permanent
housing and greater feelings of independence and privacy. Therefore, socially and economically
Housing First appears to be the best long-term investment.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
38
5
Conclusions
This study has provided enough local data about supportive housing and international data about
Housing First to know generally that both are a good social and economic investment. However, much
more specific local data related to the cost effectiveness of providing supportive housing in the local
context is needed. New research might target the following broad areas:
1. Diversity of needs among homeless people
A good general understanding of the homeless population in the Halifax Region exists, which also
corroborates with information obtained from other cities. However a more detailed and specific view of
local homeless needs would bolster the argument for longer-term action and could lead to more specific
recommendations. Improved intake data for instance and careful analysis would enable a better
understanding of individual local needs.
2. Cost of homelessness
Costs for various services, including shelters and supportive housing are generally difficult to obtain
and accurately represent. This is due to significant cost ranges, hidden costs, responsibilities shared
among various departments and jurisdictions, unwillingness from service providers and government
agencies to share the data, lack of resources and expertise among providers to gather and maintain up to
date, relevant data. There is some local information about the cost of homelessness, enough to suggest
that the pattern is similar to other cities. However there are large gaps and some inconsistencies which
require much more detailed analysis.
3. Housing First case studies
Supportive housing is presented as a spectrum with Housing First at one end. This is still a relatively
new approach, particularly in Canada. Increasingly there are more examples in the United States, which
could be collected as case studies, and correlated with locally identified needs in order to bolster the
financial and social argument for Housing First. This kind of investigation would also provide a better
understanding of the relationship between supportive housing and Housing First, and whether there is a
need for both approaches depending on the identified circumstances.
The illustrations in the Metro Halifax examples above are based on a number of assumptions about
Metro Halifax and extrapolations of information from other places. They rely on the type of
information described in Table 14 below which in some instances exists locally, in others needs to be
found. In all cases a current data base should be maintained so that: more accurate local data can be
used with the suggested tools; so there is a clear ongoing picture of what is happening, and; a way of
measuring progress. The suggested indicators of progress in Table 14 offer that possibility – a way of
gauging the difference made by investing in supportive housing or Housing First in Metro Halifax. The
indicators imply working across jurisdictional, departmental and budget boundaries within the region
and overcoming a silo approach to addressing the symptoms of homelessness.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
39
37
•
•
Decrease in the length of stay in
shelter.
Number of existing units of various types
and identified needs. (matching supply of
services to demand)
•
Increase in the supply of affordable,
supportive and permanent supportive
housing.
Local social benefits of providing supportive
housing and Housing First.
•
•
•
•
Increase in the number of people
leaving shelter to stable housing.
Reductions in days homeless,
hospitalized or incarcerated.
•
•
Decrease in the total number of
people in shelter.
Reductions in costs of providing
emergency health, mental health and
shelter services for homeless
individuals.
Number of homeless people using shelters,
the frequency of use and the duration of
stay.
Number of people using supportive housing
but require affordable housing or other
types of housing.
Number of existing housing units of
shelters, supportive housing and other
housing types in Metro Halifax.
•
•
Up to date demographic and social profile of
local homeless individuals.
•
•
•
Indicators of Success
Decrease in the number of individuals
living on the street and in other
public spaces.
Decrease in the number of homeless
people seeking shelters.
•
Local Information Needed
Number of homeless people in Metro
Halifax that fall into different need
categories.
Size and needs of homeless population
group that burdens the service sector most
(chronically homeless).
•
Understanding Costs and Housing
Approaches
Understanding Supply
of Existing Services
Understanding Demand
•
Table 14. Local Information Needed About Homelessness and Indicators of Success.37
Waiting lists for supportive housing.
• Accurate, current comparative costs per
homeless person for jail, prison, hospital,
psychiatric hospital.
• Accurate count of days spent in jail, prison,
hospital and psychiatric hospital by
homeless people in Metro Halifax.
• Current and past total annual costs in Metro
Halifax of providing shelter services to the
homeless.
•
Current expenditures on homeless by
various sectors.
• Savings incurred by each sector as a result
of investing in supportive housing.
Adapted from New York Action Plan (2005).
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
40
APPENDICES
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
41
Appendix A
Bibliography
1. Andersen, L. (1999). Connecticut Supportive Housing Demonstration Program: Program
Evaluation Report. University of Pennsylvania Health System, Department of Psychiatry
Center for Mental Health Policy and Services Research. Retrieved on January 20th, 2006 from
www.dca.state.ga.us/housing/specialneeds/programs/downloads/ HomelessActionPlan
/CSH_CTsupportHousing.PDF
2. APA Policy Guide on Homelessness (2003) Denver, Colorado:
http://www.planning.org/affordablereader/policyguides/homelessness.htm
3. Australian Housing and Urban Research Institute Research Centre. Review of Several
Homelessness Reports.
4. Berry, Mike, Chris Chamberlain, Tony Dalton, Michael Horn and Gabrielle Berman. (July,
2003). Counting the Cost of Homelessness: A Systematic Review of Cost Effectiveness and Cost
Benefit Studies of Homelessness. Prepared for the Commonwealth National Homelessness
Strategy.
5. Canadian Broadcasting Corporation. (March 10th, 2004). No Way Home: The Causes of
Homelessness. Originally Broadcast. Retrieved January 11th, 2006 from
www.cbc.ca/fifth.main_nowayhome_causes.htm
6. Community Partners Program of the Ministry of Municipal Affairs and Housing. (1999). The
Economics of Homelessness. Retrieved on January 15th, 2006 from
http://www.parkdalelegal.org/Homeless.htm
7. Corporation for Supportive Housing. Supportive Housing Saves Money - and Benefits Our
Communities! Retrieved on January 15th, 2006 from
http://www.csh.org/index.cfm?fuseaction=Page.viewPage&pageId=345&nodeID=81
8. Culhane, Dennis; and Kuhn, Randall. (1999). Applying Cluster Analysis to Test a Typology of
Homelessness by Pattern of Shelter Utilization: Results from the Analysis of Administrative
Data. American Journal of Community Psychology Vol. 26, Issue 2
9. Culhane, Dennis, Metraux, Stephen and Hadley, Trevor. (May, 2001). The Impact of
Supportive Housing for Homeless People With Severe Mental Illness on the Utilization of the
Public Health, Corrections, and Emergency Shelter Systems: The New York – New York
Initiative. Centre for Mental Health Policy and Services Research. University of Pennsylvania.
Retrieved on January 15th, 2006 from
http://www.fanniemaefoundation.org/programs/pdf/rep_culhane_prepub.pdf
10. East York/East Toronto Family Resources. (2005). Making the Case for Housing Help Centres.
Retrieved January 13, 2006 from:
http://72.14.203.104/search?q=cache:f8qP6brvhlgJ:www.eyetfrp.ca/Making%2520the%2520C
ase%2520For%2520Housing%2520Help%2520Centers1.pdf+making+the+case+for+housing+
help+centres&hl=en&gl=ca&ct=clnk&cd=1
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
42
11. Eberle, Margaret; Kraus, Deborah; Hulchanski, David; and Serge, Luba. (2001). The
Relationship Between Homelessness and the Health, Social Services and Criminal Justice
Systems: A Review of the Literature. Volume 1. Prepared for the Government of British
Columbia
12. Eberle, Margaret; Kraus, Deborah; Pomeroy, Steve; and Hulchanski, David. (2001). The Cost
of Homelessness in British Columbia. Province of British Columbia. Volume 3, Homelessness:
Causes and Effects. Retrieved on December 8th, 2005 from
http://www.hvl.ihpr.ubc.ca/pdf/EberleCosts2001.pdf
13. Ehrlich, Susan P. (April, 2002). Supportive Housing and its Impact on the Public Health Crisis
of Homelessness. Corporation for Supportive Housing. Retrieved December 8th, 2005 from
www.csh.org/index.cfm?fuseaction =Page.viewPage&pageID=3337.
14. Golden, Anne; Currie, William; Greaves, Elizabeth; and Latimer, John. (January 1999) Taking
Responsibility for Homelessness: An Action Plan for Toronto. Report of the Mayor’s
Homelessness Action Task Force, City of Toronto. Retrieved December 10, 2005 from:
http://www.toronto.ca/pdf/homeless_action.pdf
15. Halifax Regional Municipality, Planning and Development Services. (2003). Housing
Background Report: Analysis of Incomes and Shelter Costs of Income Assistance Recipients in
HRM.
16. Halifax Regional Municipality, Planning and Development Services. (2005). Homelessness in
HRM: A Portrait of Streets and Shelters, Volume 2.
17. Harder and Company Community Research. (February, 2004). The Benefits of Supportive
Housing: Changes in Residents’ Use of Public Services. Prepared for The Corporation for
Supportive Housing. Retrieved December 16th, 2005 from
http://www.csh.org/index.cfm?fuseaction=Page.viewPage&pageID=3337
18. IBI Group. (2003). Societal Cost of Homelessness. Released for Information to the Edmonton
Joint Planning Committee on Housing and the Calgary Homelessness Foundation.
19. James, D., F. Farnham, J. Cripps. (1999). Homelessness and Psychiatric Admission Rates
Through the Criminal Justice System. Lancet, 353(9159): 1158.
20. Krushel, M., S. Perry, David Bangsberg, Richard Clark, and Andrew Moss. (2002). Emergency
Department Use Among the Homeless and Marginally Housed: Results from a CommunityBased Study. American Journal of Public Health, 92(5) 7778-784.
21. Lewin Group. (2004). Cost Savings of Serving Homeless Individuals in Nine Cities. Prepared
for the Corporation for Supportive Housing (CSH)
22. Martell, JV, R. Seitz, J. Haranda, J. Koboyashi, V. Sasaki, and C. Wong. (1992)
Hospitalization in an urban homeless population: the Honolulu Urban Homeless Project.
Annals of Internal Medicine. Retrieved on January 14th, 2006 from
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=173338
4&dopt=Abstract
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
43
23. National Alliance to End Homelessness. (1991). A Plan Not a Dream: How to end
Homelessness in Ten Years. Retrieved on January 17th, 2006 from
http://www.endhomelessness.org/pub/tenyear/10yearplan.pdf
24. Pomeroy, Steve. (2005). The Cost of Homelessness: Analysis of Alternate Responses in Four
Canadian Cities. Report Prepared for National Secretariat on Homelessness.
25. Proscio, Tony. (2000). Supportive Housing and its Impact on the Public Health Crisis of
Homelessness. Corporation for Supportive Housing. Retrieved December 16th from
http://www.csh.org/html/supportiveimpact-final.pdf
26. Rehman, Laurene; and Gahagan, Jacqueline. (2003). Everyone Has a Right to A Home! A
Community Needs Assessment of Harm Reduction Supports for the Hard to House in the
Halifax Regional Municipality.
27. Roenheck, R. and C. Seibly. (1998). Homelessness: Health Service Use and Related Costs.
Medical Care, 36(8): 1256-1264.
28. Romeo, Jim. (2005). A Roof of One’s Own. Journal of the American Planning Association
29. Salit, Sharon A., Evelyn M. Kuhn, Arthur J. Hartz, Jade M. Vu, and Andrew L. Mosso. (1998).
Hospitalization Costs Associated With Homelessness in New York City. New England Journal
of Medicine. Retrieved on January 17th, 2006 from
http://content.nejm.org/cgi/content/short/338/24/1734
30. Shlay & Rossi, 1992; Sullivan & Damrosch, 1987 from: Applying Cluster Analysis to Test a
Typology of Homelessness by Pattern of Shelter Utilization: Results from the Analysis of
Administrative Data
31. Technical Assistance Collaborative Inc. (2004). Arlington Comprehensive Supportive Housing
Plan. Retrieved March 9, 2006 from:
https://www.arlingtonva.us/Departments/HumanServices/pdf/supportiveHousingPlan.pdf
32. Tumarkin, Laurel. (2003). A Work in Progress: The City’s Rental Assistance Program for
Working Homeless Adults. A Policy Report from HELP USA. Retrieved on January 22nd, 2006
from http://www.helpusa.org/advocacy/RAP%20paper%20(print%20copy).pdf
33. US Department of Housing and Urban Development. (2005). Strategies for Preventing
Homelessness. Retrieved March 8, 2006 from:
http://www.urban.org/UploadedPDF/1000874_preventing_homelessness.pdf
34. US Department of Housing and Urban Development. (2004). Strategies for Reducing Chronic
Street Homelessness. Retrieved January 13, 2006 from:
http://www.urban.org/UploadedPDF/1000775.pdf
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
44
Appendix B
Annotated Bibliography: Selected Literature Review
1. Andersen, L. (1999). Connecticut Supportive Housing Demonstration Program:
Program Evaluation Report. University of Pennsylvania Health System, Department
of Psychiatry Center for Mental Health Policy and Services Research. Retrieved on
January 20th, 2006 from:
www.dca.state.ga.us/housing/specialneeds/programs/downloads/
HomelessActionPlan/CSH_CTsupportHousing.PDF
Research Question: Does the Connecticut Supportive Housing Demonstration program reduce health
and social service costs, enhance quality of life for residents, and allow residents to meet employment
and vocational needs?
Findings: The Connecticut Supportive Housing Demonstration program (initiated in 1992) supplies
281 permanent supportive housing units for homeless and at-risk populations. Data on 430 residents’
service usage over a three-year period was analyzed. Prior to entering supportive housing, total health
costs averaged $11,759 (US) per person. The study found that inpatient costs reduced from an average
of $4,944 to $2,851; costs for medical supplies and home health care reduced from an average of
$4,731 to $1,898 per person. As well, the costs of prescription drugs decreased from $1,904 to $1,366.
The study concluded that the Program reduced the utilization of restrictive and expensive health
services, enhanced the quality of life of the residents, and allowed tenants to attend their employment
and vocational needs.
2. Berry, Mike; Chamberlain, Chris; Dalton, Tony; Horn, Michael; and Berman,
Gabrielle. (2003). Counting the Cost of Homelessness: A Systematic Review of Cost
Effectiveness and Cost Benefit Studies of Homelessness. Prepared for the
Commonwealth National Homelessness Strategy.
Research Question: What does the literature conclude on the costs of homelessness and/or the benefits
for various intervention programs, including supportive housing? Secondly, do the studies have a sound
approach? What are the strengths and weaknesses, and are there any gaps in the analysis and findings?
Were there any biases or limitations in the data used?
Findings: All studies reviewed identified a cost benefit through an investment in supportive housing.
However, the limitations of the studies include:
 Heavy reliance on administrative and/or survey data, where significant gaps may be present;
 Lack of quality data sets on program use or fragmented data;
 Unreliable or incomplete information on participation recall;
 Although cost savings for supportive housing are assessed, they do not record any increased costs
in the utilization of support and other services;
 Sample sizes are generally small; and
 Time frames for assessing the cost and benefits of supportive housing are often too short.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
45
3. Culhane, Dennis, Metraux, Stephen and Hadley, Trevor. (2001). The Impact of
Supportive Housing for Homeless People With Severe Mental Illness on the Utilization
of the Public Health, Corrections, and Emergency Shelter Systems: The New York –
New York Initiative. Centre for Mental Health Policy and Services Research.
University of Pennsylvania. Retrieved on January 15th, 2006 from:
http://www.fanniemaefoundation.org/programs/pdf/rep_culhane_prepub.pdf
Research Question: What is the cost of service utilization (e.g. public shelters, public hospitals,
Medicaid-funded services, veteran’s inpatient service, state psychiatric inpatient services, state prisons,
jails) for homeless individuals with severe mental illness with no housing compared to individuals with
the same disabilities living in supportive housing?
Findings: This study reviewed data on 4,679 homeless people with severe mental disorders placed in
supportive housing in New York City between 1989 and 1997. Prior to placement in housing, Culhane
et al found that homeless people with severe mental illness used an average of $40,449 (US 1999)
worth of public services per person per year. Placement in supportive housing after two years equated
to a $12,145 net reduction in cost of service per person. The study concludes that 95% of the cost of
supportive housing for people with severe mental illness is recovered in service reductions attributed to
housing placement.
4. Eberle, Margaret; Kraus, Deborah; Hulchanski, David; and Serge, Luba. (2001).
The Relationship Between Homelessness and the Health, Social Services and Criminal
Justice Systems: A Review of the Literature. Volume 1. Prepared for the Government
of British Columbia.
Research Question: Do homeless individuals use social services such as health, social services, and
criminal justice systems more than others? If so, what are the related costs?
Findings: The Government of British Columbia examines the relationship between homelessness and
service utilization by reviewing and summarizing published literature from Canada and the United
States. The literature shows that there is a strong correlation between homelessness and the use of
health care services, social services, and criminal justice system. Individuals that do not have safe,
secure, affordable, and permanent shelter are more likely to have greater health issues, social problems,
and criminal involvement than the general public. To address these problems, the homeless use a
greater number, frequency, and duration of social services such as hospitals, emergency services,
shelters, and correctional institutions.
The interest in estimating the cost of homelessness has been investigated by Culhane (in New York)
and McLaughlin (in Toronto). Although little research currently deals with this issue, the bulk of the
research is cited from the United States. Further research is needed to learn more about the homeless
people in Canada, their needs, use of public services, and their effect on these services.
Research confirms that preventative measures, such as affordable and supportive housing, are more
cost-effective than standard homeless shelters. If homelessness is prevented in the first place, then the
problem of “pay now or pay more later” can be avoided. Social costs related to the homeless, society,
and government are rarely included in the literature. The literature’s focus on solely monetary costs
underestimates the true cost of homelessness.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
46
5. Eberle, Margaret; Kraus, Deborah; Pomeroy, Steve; and Hulchanski, David. (2001).
The Cost of Homelessness in British Columbia. Province of British Columbia. Volume
3, Homelessness: Causes and Effects. Retrieved on December 8th, 2005 from:
http://www.hvl.ihpr.ubc.ca/pdf/EberleCosts2001.pdf
Research Question: What is the cost of homelessness to the health care, social services, and criminal
justice system? Can the government decrease future expenditures by investing in preventative measures
such as adequate and affordable housing?
Findings: Eberle et al found that in British Columbia (between 1998-1999) providing major
government health care, criminal justice and social services (excluding housing) to homeless
individuals in the study cost, on average 33% more than to housed individuals ($24,000 compared to
$18,000). The combined service and shelter costs of homeless people in this study ranged from $30,000
to $40,000 on average per person for one year, while the combined costs of service and housing for the
housed individuals ranged from $22,000 to $28,000 per person per year (assuming they remained in
supportive housing). The study concludes that a preventative approach to homelessness is more costeffective than the emergency or reactive approach for the study sample (15 individuals).
6. Ehrlich, Susan P. (April, 2002). Supportive Housing and its Impact on the Public
Health Crisis of Homelessness. Corporation for Supportive Housing. Retrieved
December 8th, 2005 from:
www.csh.org/index.cfm?fuseaction=Page.viewPage&pageID=3337.
Research Question: What are the reasons behind changes in service utilization (medical
hospitalizations, emergency room visits, detox drug treatment days, and mental health crisis
encounters) after placing homeless individuals in supportive housing?
Findings: The Corporation for Supportive Housing conducted a 4-year study of 199 residents who
moved into Cannon Kip Community House (CK) in San Francisco. The study determines that 80% of
the residents have mental health issues, 93% have substance abuse issues, and 20% have AIDS. Of
these clients, 57% of the residents were not using substance abuse services prior to living at CK, 52%
did not use any mental health service, and 30% used neither mental health nor substance abuse
services. Finally, the change in service use was determined for lowest users, low users, high users, and
highest users. Between 31% and 63% reduction in service use was calculated for the various user
categories (for residents of CK supportive housing).
7. Golden, Anne; Currie, William; Greaves, Elizabeth; and Latimer, John. (1999)
Taking Responsibility for Homelessness: An Action Plan for Toronto. Report of the
Mayor’s Homelessness Action Task Force, City of Toronto. Retrieved December 10,
2005 from: http://www.toronto.ca/pdf/homeless_action.pdf
Research Questions: What are the causes of homelessness, what types of people are homeless, what
prevents effective solutions to homelessness, what methods can overcome preventative barriers, and
what are the roles each level of government in preventing homelessness?
Findings: With specific regard to supportive housing, the study concludes that some form of
supportive housing provides a stable housing alternative for the chronically homeless population and
for those who have demonstrated difficulty in maintaining stable housing. The study strongly
recommends that the chronically homeless population in Toronto (approximately 29,000 people) be
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
47
diverted from the emergency shelter system to permanent supportive housing due to the fact that almost
half the resources of the shelter system are devoted to providing what is effectively permanent housing
for this relatively small group.
8. Harder and Company Community Research. (February, 2004). The Benefits of
Supportive Housing: Changes in Residents’ Use of Public Services. Prepared for The
Corporation for Supportive Housing. Retrieved December 16th, 2005 from:
http://www.csh.org/index.cfm?fuseaction=Page.viewPage&pageID=3337
Research Questions: Is supportive housing an effective and economical alternative to the emergency
or sheltered housing services that the homeless often receive in San Francisco? What are the changes in
use of mental health services, behaviour health care services, substance use treatment, and the criminal
justice system by people in supportive housing?
Findings: The study follows 279 residents in San Francisco who were heavy users of publicly funded
services:
 95% of study participants used public health services;
 76% used outpatient or inpatient services at the local public hospital;
 47% used city funded substance use treatment services;
 65% used publicly funded mental health services outside the hospital system; and
 40% received health care during a stay in the county jail.
It is estimated that 12,500 people are homeless in San Francisco (1.6% of the city’s population). Their
usage comprises 26% of hospital days, 24% of emergency room visits, and 22% of hospital admissions.
After one year in supportive housing emergency room visits dropped from an average of 1.94 to 0.85
visits/person/year (56% decrease); medical emergency room visits declined from 1.60 to 0.65
visits/person/year (59% decrease); inpatient care were reduced from 1.58 to 1.0 visits/person/year (37%
decrease); and psychiatric emergency room visits decreased from 0.33 to 0.20 visits/year (39%
decrease).
Similar cost savings were observed for hospital use. After one year in supportive housing, hospital
stays decreased from 0.34 to 0.19 days/person/year; medical hospital stay fell from 0.19 to 0.11
days/person/year; and psychiatric hospital stay decreased from 0.15 to 0.08 days/person/year.
Findings from San Francisco conclude that permanent supportive housing can provide stable housing
alternatives to the homeless while reducing government costs. In San Francisco, the total cost of
hospital services fell from $737,000 to $404,000, a savings of over $334,000 or $1,197 per person (all
$US). The total cost savings of residential mental treatment was over $50,000 per person per year.
Lastly, incarceration fell 44% after participates entered supportive housing. Before starting the
program, residents spent an average of 1.58 days/person/year in prison. This number decreased to 1.12
days/person/year.
9. IBI Group. (2003). Societal Cost of Homelessness. Released for Information to the
Edmonton Joint Planning Committee on Housing and the Calgary Homelessness
Foundation.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
48
Research Question: What are the societal costs of homelessness for Calgary and Edmonton?
Findings: Based on a collection of data from service providers. The study used the following definition
of homelessness to determine its outcomes:
“Those who are absolutely, periodically, or temporarily without shelter, as well as those who are at
substantial risk of being on the street in the immediate future.”
The net annual societal costs of homelessness (based on service provision costs, cost avoidance, and
emergency shelter capital costs) were determined to be $67.5 million for Calgary and $46.9 million for
Edmonton. Additionally, the report concludes that financial reasons alone are sufficient to propose that
a homeless prevention model is less costly than the current emergency model.
10. Krushel, M., S. Perry, David Bangsberg, Richard Clark, and Andrew Moss. (2002).
Emergency Department Use Among the Homeless and Marginally Housed: Results
from a Community-Based Study. American Journal of Public Health. 92(5) 7778-784
Research Question: What are the factors associated with emergency department use among homeless
and marginally housed people?
Findings: A study of 2578 homeless individuals found that 40% of respondents had one or more
emergency department encounters in the previous year (a rate three times the US norm). However,
persons classified as “repeat users” (those who have four or more emergency department encounters in
the past year) accounted for the majority (54.4%) of the total emergency department use (their numbers
account for only 8% of the total sample in this study). Factors associated with high use rates included:
less stable housing, victimization, arrests, physical and mental illness, and substance abuse. Previous
research has linked housing instability with more use of ambulatory care and less use of acute care
services. This study lends support to such findings. The effects of lack of housing, which include
exposure to violence, problems in managing chronic medical conditions, and difficulty in planning for
health care, frequently increase emergency department use.
11. Lewin Group. (November, 2004). Costs of Serving Homeless Individuals in Nine
Cities. The Partnership to End Long-Term Homelessness.
Research Question: What is the cost of homeless in the United States, measured through service use
in supportive housing, jail, prison, shelter, psychiatric hospitals, and hospitals?
Findings: The Lewin Group determined that the approximate cost of homelessness per person per day
(when all service costs are combined) from greatest to least is: San Francisco $3,557; Seattle $2,966;
Boston $2,594; Los Angeles $2,294; Columbus $2,227; Phoenix $2,126; Atlanta $2,116; New York
$1,986; and Chicago $1,804 (all $US).
12. Padget, Deborah, Leyla Gulcur, and Sam Tsemberis. (2006). Housing First Services
for People Who are Homeless with Co-occurring Serious Mental Illness and Substance
Abuse. New York University School of Social Work.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
49
Research Questions: Is the Housing First model appropriate and/or effective for individuals with
mental illness and substance abuse issues? What is the difference in housing retention between those in
standard care and those in Housing First?
Findings: The report studies tenure of 225 mentally ill adults over a period of two years. Results show
that Housing First individuals and standard care individuals have the same reduction rates in alcohol
and drug use. However, to realize this reduction in use, standard care services were much more
intensive and costly. These findings show that “dual diagnosed” adults can remain stably housed
without increasing their substance use. Thus, Housing First programs favouring immediate housing and
consumer choice deserve consideration as a viable alternative to standard care.
13. Pathways to Housing. (October, 2005). Providing Housing First and Recovery Services
for Homeless Adults With Severe Mental Illness. Psychiatric Services, Vol. 56, 10.
Retrieved on March 19th, 2006 from:
http://ps.psychiatryonline.org/cgi/reprint/51/4/487?maxtoshow=&HITS=10&hits=10
&RESULTFORMAT=&fulltext=pathways+to+housing&searchid=1&FIRSTINDEX
=0&sortspec=relevance&resourcetype=HWCIT
Research Question: How effective is the Housing First model in housing retention for homelessness
adults with severe mental illness?
Findings: Pathways to Housing, the organization that founded concept of “Housing First”, examines
242 individuals to determine the effectiveness of the Housing First model. Over a five year period, 88%
of the program’s tenants remained housed, compared to 47% of residents in the standard housing
program. Pathways to Housing concludes that contrary to popular belief, Housing First can
successfully help a broad range of homelessness types gain and retain affordable housing. Clients with
severe psychiatric disabilities and addictions, for example are capable of succeeding in the Housing
First model when they are provided with the opportunity and required community support services.
14. Pomeroy, Steve. (2005). The Cost of Homelessness: Analysis of Alternate Responses in
Four Canadian Cities. Report Prepared for National Secretariat on Homelessness.
Research Questions: What institutional, emergency, and supportive housing costs exist in Montreal,
Toronto, Halifax and Vancouver? What are the cost estimates for the future development of
institutional, emergency and supportive housing at today’s costs?
Findings: Key findings from a cost analysis of existing facilities in the four cities include:
 Overall, costs tend to be significantly higher for institutional responses than is the case for
community/residentially based options;
 Emergency services tend to have higher costs than the community/residentially based options;
and
 Cost estimates for transitional and supportive housing suggest a wide range mainly due to the
very diverse range of client types. However, even at the high end of the spectrum, these costs
are lower than institutional and emergency costs.
When estimates are developed for new construction costs and these are combined with current support
costs across a range of support levels (from no supports to fairly intense), the costs of supportive
housing options remain significantly lower than costs of institutional and emergency services for
comparable sub-populations of homeless individuals and families.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
50
15. Proscio, Tony. (2002). Supportive Housing and its Impact on the Public Health Crisis
of Homelessness. Corporation for Supportive Housing. Retrieved December 16th
from: http://www.csh.org/html/supportiveimpact-final.pdf
Research Question: What are the costs of emergency room utilization, inpatient stays, and psychiatric
health care after moving into supportive housing?
Findings: Within one year after moving into supportive housing, the use of emergency rooms fell by
58% (equating to a total annual cost savings of $56,691); the annual use of hospital inpatient beds fell
by 57% (from 531 days to 239 days); and the annual total days of residential mental health treatment
fell from 316 to 0 in two years (reducing the annual cost of residential mental health treatment from
$39,195 to $0).
16. Roenheck, R. and Seibly, C. (1998). Homelessness: Health Service Use and Related
Costs. Medical Care, 36(8): 1256-1264.
Research Question: What are the costs of health service use for homeless and domiciled veterans
hospitalized in psychiatric and substance abuse units at Department of Veterans Affairs (VA) medical
centers, across the United States?
Findings: Combining patients from general psychiatry and substance abuse programs, the average
annual cost of care for homeless veterans was $27,206 (after adjusting for other factors); this was
$3,196 (13.3%) higher than the cost of care for domiciled veterans. Homelessness was found to be
associated with increased total health care costs of 13% across the entire year. The higher costs for
homeless persons in the period after discharge were primarily attributable to higher hospital
readmission rates, but also to greater use of outpatient services.
17. Salit, Sharon; Kuhn, Evelyn; Hartz, Arthur; Vu, Jade; and Mosso, Andrew. (1998).
Hospitalization Costs Associated With Homelessness in New York City. New England
Journal of Medicine. Retrieved on January 17th, 2006 from
http://content.nejm.org/cgi/content/short/338/24/1734
Research Questions: In New York, what is a homeless individual’s average length of stay in the
hospital? What are the estimated costs associated with hospitalization?
Findings: Using discharge data on 18,864 admissions of homeless adults to New York City’s public
general hospitals and 383,986 non-maternity admissions of other low-income adults to all general
hospitals in New York City, the study found that homeless patients stayed, on average, 4.1 days (36%)
longer per admission than other patients (even after adjustments were made for differences in rates of
substance abuse and mental illness and other clinical and demographic characteristics). The cost of the
additional days per discharge averaged $4,094 for psychiatric patients, $3,370 for patients with AIDS,
and $2,414 for all other types of patients.
18. US Department of Housing and Urban Development. (2005). Strategies for Preventing
Homelessness.
Retrieved
March
8,
2006
from:
http://www.urban.org/UploadedPDF/1000874_preventing_homelessness.pdf
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
51
Research Questions: What communities have implemented community-wide strategies to prevent
homelessness and document their effectiveness? What approaches and their component activities can
contribute to strategies for other communities and the housing field in general? How should prevention
programs be evaluated for their effectiveness?
Findings: The study found that permanent supportive housing works to prevent initial homelessness,
re-house people quickly if they become homeless, and help the chronically homeless population leave
the streets. Evidence collected from Massachusetts indicates declining rates of homelessness among
people with serious mental illness admitted to state psychiatric hospitals over the 10 year period during
which the Department of Mental Health was expanding housing with supportive services.
19. The State of New York. (2005). “New York Action Plan.” Retrieved March 13 th, 2006
from:
http://www.nyc.gov/html/endinghomelessness/downloads/pdf/implem-update0904.pdf
Research Question: How can the City of New York reduce homelessness by two thirds during the
next five years (starting January, 2005)?
Findings: Central to the strategy is a shift in the New York’s response to homelessness: away from
simply sheltering individuals and families to programs and interventions that aim to solve
homelessness. Included amongst these programs is a focus on supportive housing, and more
specifically, Housing First. The five-year action plan contains 60 initiatives divided into nine chapters:
1) Overcome street homelessness;
2) Prevent homelessness;
3) Coordinating discharge planning;
4) Coordinating city services and benefits;
5) Minimize disruptions to families who experience homelessness;
6) Minimize duration of homelessness;
7) Shift resources into preferred services;
8) Provide resources for vulnerable populations to access and afford housing; and
9) Measure progress, evaluate success, and invest in continuous improvement.
For each of the nine chapters, indicators where created to measure success. The key indicators are:
decrease in the number of individuals living on the street, increase in the number of people leaving
shelter to stable housing, increase in the supply of affordable, service-enriched and supportive housing,
decrease in the number of applications for shelter, decrease in the length of stay in shelter, and decrease
in the total number of people in shelter.
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
52
Appendix C
Housing First Programs in the United States
Program Name
Organization and/or Lead
Agency
Location
Beyond Shelter
Catholic Social Services
Anchorage, AL
Brainerd Hope
Crow Wing County, MN
Family Housing Collaborative
Lutheran Social Service of
Minnesota
The Community Partnership for the
Prevention of Homelessness
Community Shelter Board
HomeStart
HomeStart
Boston, MA
Housing First
Beyond Shelter
Los Angeles, CA
Housing First Collaborative
Emergency Housing Consortium
Santa Clara County, CA
Housing First Initiative
Grand Rapids, MI
Housing Opportunities for Women
The Salvation Army Booth Family
Services
Housing Opportunities for Women
Housing Services Program
St. Stephens Housing Services
Hennepin County, MN
It’s All About the Kids
Minneapolis, MN
Partnerships for Permanent
Housing
Permanent Access to Housing
Lutheran Social Services of
Minnesota
Montgomery County Coalition for
the Homeless
Seattle Emergency Housing Service
Shelter to Independent Living
Tabor Community Services
Lancaster, PA
Community Care Grant
Washington, DC
Columbus, OH
Chicago, IL
Montgomery County, MD
Seattle, WA
Source: National Alliance to End Homelessness Housing First Network
The Cost of Homelessness and the Value of Investment in Housing Support Services in the Halifax Regional Municipality
53