摘要：Permanent supportive housing (PSH) is an intervention to address long-term homelessness. Evidence has resulted in a shift in US policy toward using PSH rather than shelters and transitional housing. Despite recognizing that individuals transitioning from homelessness to PSH experience a high burden of disease and health disparities, public health research has not considered whether and how PSH improves physical health outcomes. Based on diverse areas of research, we argue that in addition to improved access to quality health care, social determinants of health (including housing itself, neighborhood characteristics, and built environment) affect health outcomes. We identify implications for practice and research, and conclude that federal and local efforts to end long-term homelessness can interact with concurrent efforts to build healthy communities. Long-term homelessness is a significant determinant of poor health. Lengthy exposure to weather, infections, drugs, and violence, coupled with limited access to ongoing health care, is associated with a high incidence of acute and chronic health problems and premature mortality. 1,2 Launched in 1985 through pilot programs funded by the Robert Wood Johnson Foundation and the Pew Charitable Trust, Health Care for the Homeless programs now exist in cities throughout the United States and are designed to address the significant disease burden of this vulnerable population. 3,4 In addition, efforts to address the rise of homelessness during the past four decades have resulted in the recognition that housing is an important part of health care service delivery for persons who have experienced homelessness 5 and is cost effective 6–8 and consistent with basic human rights. 9 These factors have contributed to a remarkable shift in US policy toward addressing long-term homelessness through permanent supportive housing (PSH) rather than relying on shelters and transitional housing. 10 PSH denotes programs that provide access to affordable community-based housing along with flexible support services intended to meet a broad array of health and psychosocial needs. 11 Typically, housing can be a congregate residence with services provided on site (i.e., single-site model) 12 or an apartment rented from a private landlord with services provided by mobile community treatment teams (i.e., scatter site). 13 Today, there are nearly 240 000 PSH units across the country, a figure that has increased by an average of 12 000 units annually since 2006. 14 Missing from the public health literature is evidence on whether and how PSH improves physical health outcomes. Instead, research on PSH has focused on residential stability and behavioral health outcomes. 15 This focus is not surprising given that PSH predominantly serves individuals with serious mental illness (SMI) and substance abuse problems who represent a disproportionate number of those who are long-term homeless. 1,16 Yet the omission of physical health outcomes is particularly problematic because in addition to homelessness, significantly higher morbidity and mortality rates exist among people with SMI. 17 Compared with the general population, people with SMI die at a younger age largely because of preventable medical conditions (e.g., diabetes, cardiovascular disease), suboptimal medical care, elevated rates of cardiovascular risk factors (e.g., smoking, lack of physical activity), and the uncontrolled or unmanaged cardiometabolic side effects of antipsychotic medications. 18 Those entering PSH carry a significant disease burden based on multiple and significant risk categories (i.e., homeless and SMI) that exacerbate known health disparities. 19 As a first step to considering whether PSH improves physical health outcomes and has the potential to reduce health disparities, we examine how PSH could affect physical health conditions and disease burden. Drawing from distinct and diverse areas of research, we consider different pathways through which PSH could affect health outcomes, namely, through health care and health interventions, through the provision of housing itself, and through the neighborhood and built environment in which it is located. Findings can be used to guide public health research and action.
