The current observational study aimed to address the question of whether among chronically homeless adults with diverse health problems, all of whom would have eventual access to permanent supported housing, those who receive Residential Treatment First (RTF) before obtaining independent housing achieve better psychosocial outcomes than those who immediately receive Independent Housing First (IHF). It should be stated that this was not a test of residential/transitional treatment, but a study that utilized existing data. Participants were grouped based on whether they had spent 2 weeks or more in transitional or residential housing at the time of entry into the program. The results generally did not support the study hypothesis. Although both the RTF and IHF group showed improvements in various psychosocial domains over time, clients in the IHF group were clearly housed in their own place more days, despite starting with more days homeless at baseline. The IHF group also had less days incarcerated overall and reported more choice over their treatment services over time. However, it is notable that since this was not a randomized clinical trial, clients in the RTF group showed evidence of slightly more severe problems as baseline, including a higher proportion of participants with substance use disorders (83.5% to 70.5%), similar to what has been found in a previous study (O'Connell, et al., 2009
). The RTF group remained more reliant on transitional/residential treatment over time, and as expected, incurred more substance abuse service costs, but there were no differences on days of homelessness.
When analyses were repeated to include only participants with substance use disorders, results were mostly similar. However, it is notable that one difference found was that the RTF group reported greater housing satisfaction. There may have been more treatment-related activities and services in the RTF group leading to greater satisfaction, suggesting the possibility there may be some benefit with the increased cost incurred by the RTF. Overall, it was found that participants with a substance use disorder were comparatively worse at baseline than participants without a substance use disorder on a range of variables, including homelessness and psychotic behavior. When these baseline differences were controlled for, it was found that participants with a substance use disorder continued to persist in many of these problems over time, including incurring relatively high healthcare costs.
Taken together, these results suggest that clients with substance use disorders do experience more problems living independently, but prior transitional/residential treatment may not particularly benefit them any more than Housing First approaches, especially on independent housing outcomes. A further interpretation is that clients who use transitional/residential treatment continue to use more transitional/residential treatment over time and these settings may be offering supports not provided in independent housing. However, further study is needed and the precise benefits of transitional/residential treatment remain poorly identified in the literature (Kertesz, et al., 2009
). In particular, this study was limited by its observational design because there was no random assignment to the RTF or IHF groups; and as a result differences between participants at baseline could only be controlled for statistically.
The data suggest a need to evaluate RTF and IHF with random assignment before definite conclusions can be made. There may have been influential unmeasured variables that were not accounted for. Conversely, controlling for covariates in the analyses may have limited accurate portrayal of profiles (e.g., controlling for substance use while examining incarceration). Clients in the RTF group may have had more severe problems, warranting transitional/residential treatment before being placed into independent housing. It can be assumed that clinical staff placed clients in transitional/residential treatment based on some subjective judgment of client's capacity to live independently. Their relative improvements may have occurred before the study; as a possible clue, there were no baseline group differences on substance abuse although there was a higher proportion of substance disorders in the RTF group. Future studies should address these issues with experimental designs.
More study is needed on what are the benefits of transitional/residential treatment. Transitional/residential treatment may offer therapeutic settings where staff and peers are readily available (Tsai, et al., in press
), but the immediate and long-term measured effects have not been adequately studied. Moreover, transitional/residential treatment may be viable, temporary options in the midst of rising real estate prices and scarcities in housing supply. Although the results of this study do not favor transitional/residential treatment, the clinical implications are not to disregard all instances when clients may want or need it. Instead, the results suggest that clinicians should not assume transitional/residential treatment prepares clients for more independent living and that there is a pay-off in the long run. This study also highlights a well - known problem among the homeless, which is substance abuse (Koegel & Burnam, 1988
; Koegel, Sullivan, Burnam, Morton, & Wenzel, 1999
) and reiterates the importance of substance abuse treatment for this population.
The results of this study may have been limited by the time periods examined. Participants were grouped on the basis of whether they had spent more than 2 weeks in transitional/residential treatment. While this, in itself, may not be an adequate dose of such treatment, the RTF sample averaged 47 days of residential treatment, which is a substantial dose. Because this grouping was only based on the 3 months before and after baseline, participants that had significant tenure in transitional/residential treatment before this time may not have been properly identified, reflecting the inevitable trade-off between generalizability and specificity. Results of the study may be more generalizable than others in that this was a multi-site study involving numerous agencies and housing settings. However, that also undoubtedly introduced substantial variations between sites, agencies, and settings and the results may not apply to all housing units. Nonetheless, this observational study found no clinical advantages for clients who had residential treatment or transitional housing prior to entry into community housing, but they incurred higher substance abuse service costs.