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Mary E. Larimer, PhD; Daniel K. Malone, MPH; Michelle D. Garner, MSW, PhD; David C. Atkins, PhD; Bonnie Burlingham, MPH; Heather S. Lonczak, PhD; Kenneth Tanzer, BA; Joshua Ginzler, PhD; Seema L. Clifasefi, PhD; William G. Hobson, MA; G. Alan Marlatt, PhD

JAMA. 2009;301(13):1349-1357.

Context  Chronically homeless individuals with severe alcohol problems often have multiple medical and psychiatric problems and use costly health and criminal justice services at high rates.

Objective  To evaluate association of a "Housing First" intervention for chronically homeless individuals with severe alcohol problems with health care use and costs.

Design, Setting, and Participants  Quasi-experimental design comparing 95 housed participants (with drinking permitted) with 39 wait-list control participants enrolled between November 2005 and March 2007 in Seattle, Washington.

Main Outcome Measures  Use and cost of services (jail bookings, days incarcerated, shelter and sobering center use, hospital-based medical services, publicly funded alcohol and drug detoxification and treatment, emergency medical services, and Medicaid-funded services) for Housing First participants relative to wait-list controls.

Results  Housing First participants had total costs of $8 175 922 in the year prior to the study, or median costs of $4066 per person per month (interquartile range [IQR], $2067-$8264). Median monthly costs decreased to $1492 (IQR, $337-$5709) and $958 (IQR, $98-$3200) after 6 and 12 months in housing, respectively. Poisson generalized estimating equation regressions using propensity score adjustments showed total cost rate reduction of 53% for housed participants relative to wait-list controls (rate ratio, 0.47; 95% confidence interval, 0.25-0.88) over the first 6 months. Total cost offsets for Housing First participants relative to controls averaged $2449 per person per month after accounting for housing program costs.

Conclusions  In this population of chronically homeless individuals with high service use and costs, a Housing First program was associated with a relative decrease in costs after 6 months. These benefits increased to the extent that participants were retained in housing longer.

Author Affiliations: Department of Psychiatry and Behavioral Sciences (Drs Larimer and Atkins), Addictive Behaviors Research Center (Ms Burlingham and Drs Clifasefi and Marlatt), and Alcohol and Drug Abuse Institute (Drs Lonczak and Ginzler), University of Washington, Seattle; Social Work Program, University of Washington, Tacoma (Dr Garner); and Downtown Emergency Service Center, Seattle, Washington (Messrs Malone, Tanzer, and Hobson).

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