Predicting Staying In or Leaving 

Permanent Supportive Housing 

That Serves Homeless People with 

Serious Mental Illness 

U.S.Department of Housing and Urban Development 
 

Office of Policy Development and Research 
 
Predicting Staying in or Leaving 
 

Permanent Supportive Housing 
 

That Serves Homeless People with 
 

Serious Mental Illness
 

Final Report 

Prepared for: 

U.S. Department of Housing and Urban 
 

Development 
 

Office of Policy Development and 
 

Research 
 

Prepared by: 
 

Yin-Ling Irene Wong, CMHPSR 
 

Trevor R. Hadley, CMHPSR 
 

Dennis P. Culhane, CMHPSR 
 

Steve R. Poulin, CMHPSR 
 

Morris R. Davis, MDAC 
 

Brian A. Cirksey, MDAC 
 

James L. Brown, MDAC 
 

M. Davis and Company, Inc (MDAC) 

Philadelphia, PA 

 University of Pennsylvania 

Center for Mental Health Policy and Services Research 

 (CMHPSR) 

 Philadelphia, PA 

 March 2006 
ACKNOWLEDGEMENTS 

Many individuals and organizations have contributed to the completion of this project. 

We would especially like to thank the following: 

• The City of Philadelphia’s Office of Public Health’s Institutional Review Board. 

•	 The staff and managers of the City of Philadelphia’s Department of Behavioral 

Health/Mental Retardation Services. 

•	 The residential support staff, case managers and supervisors of the city’s 

permanent housing programs who tirelessly serve the city’s homeless and 

mentally ill populations. 

•	 Our advisory team members, Carol Caton and Michale Covone who have 

contributed their time, knowledge and expertise. 

•	 Paul Dornan, our project Government Technical Representative from the U.S. 

Department of Housing and Urban Development (HUD)’s Office of Policy 

Development and Research (OPDR), for providing us with indispensable support, 

insights and encouragement throughout the study. Additionally, Kevin Neary, 

also from HUD’s OPDR, provided invaluable support. 

We appreciate the significant contributions that the above individuals made to the 

implementation of the research project and writing of this report. They are not 

responsible for any errors or omissions. The findings and views herein are those of 

the contractors and authors. 

The contents of this report are the views of the contractor and do not necessarily 

reflect the views or policies of the U.S. Department of Housing and Urban 

Development or the U.S. Government. 
Foreword 

The Permanent Housing component of the Supportive Housing Program, the 

Department’s principal program to meet the needs of homeless people with disabilities, 

was established to offer homeless people with disabilities, including mental illness, an 

assurance of permanent housing and appropriate supportive services. The program is 

designed to provide a structure that counteracts the disruptions of both homelessness and 

disability. However, while many formerly homeless people remain in permanent 

supportive housing for many years, substantial numbers leave within months of entry. 

The questions of why people leave permanent housing and what happens to them 

constitute the principal focus of this study. 

This study examines the experience of some 943 residents of permanent supportive 

housing in Philadelphia during the period from 2001 to 2005. The capability to merge 

Homeless Management Information System (HMIS) data and administrative data in 

Philadelphia, Pennsylvania, made possible a viable strategy to track over time a highly 

elusive population -- formerly homeless people with mental illness who had left 

permanent supportive housing. 

The study shows that it is not necessarily a bad thing that some people leave “permanent” 

supportive housing. Those who left and the circumstances of their departure were highly 

divergent, and who left and how was significantly related to the stability of their housing 

and the independence of their lives, both in the short- and longer-term. Three-fifths of 

those who left HUD-supported Permanent Housing in Philadelphia left voluntarily, either 

to pursue better housing or to move away from problems they were experiencing in the 

permanent supportive housing. The remaining two-fifths left involuntarily, having been 

asked to leave because they violated program rules or because they were adjudged by 

staff incapable of maintaining themselves in the permanent supportive housing 

environment. Those who left under positive circumstances were far more likely to move 

to more stable and independent housing, to stay in that housing over time and to use 

fewer mental health services post-departure than those who left more negatively. The 

study also found that, based on the variables included, there would have been no way to 

predict at entry into permanent supportive housing who would stay or leave, either 

positively or less so. 

This study makes a valuable contribution to our understanding of how the structure of 

permanent supportive housing and the use of various means of stabilization at critical 

junctures in a resident’s stay can promote more stability and, thereby, greater health and 

independence, among those living there, whether they stay or subsequently leave. 

 Darlene F. Williams

 Assistant Secretary for 

Policy Development and Research 
TABLE OF CONTENTS 
 

ACKNOWLEDGEMENTS.....................................................................II 

EXECUTIVE SUMMARY......................................................................VII 
 

Background...........................................................................................vii 
 

Method................................................................................................ix 
 

Findings...............................................................................................ix 
 

Housing Tenure of Permanent Housing Residents...............................................x 
 

Differences between Those Who Leave Permanent Housing and Those Who Stay........xi 
 

Categories of Those leaving HUD- Funded Permanent Housing..............................xi 
 

Circumstances of Departure from HUD-Funded Permanent Housing......................xiii 
 

Post-Permanent Housing Residential Careers of Leavers.....................................xv 
 

Implications and Recommendations..............................................................xv 
 

CHAPTER 1: INTRODUCTION AND OVERVIEW OF THE STUDY................1 

Introduction............................................................................................1 

Background............................................................................................2 

 HUD-Assisted Permanent Housing.............................................................2 

 Limited Length of Stay for Participants of Permanent Housing Programs...............3 

 Characteristics Associated with Housing Instability and Leaving Permanent 
 

Housing.............................................................................................5 
 

Research Questions...............................................................................5 
 

Study Site Selection..............................................................................6 
 

The Rest of this Report...........................................................................7 
 

CHAPTER 2: METHODS........................................................................9 

Introduction............................................................................................9 
 

Retrospective Tracking of Leavers and Stayers of Permanent Housing through the 
 

Integrated Longitudinal Administrative Database................................................9 

 Selection of the Retrospective Tracking Sample.............................................9 

 The Integrated Longitudinal Administrative Database....................................10 

 Data Quality Issues of Longitudinal Integrated Database.................................11 
 

Data Analysis....................................................................................11 
 

Prospective Tracking of Leavers and Stayers of Permanent Housing Through 

Interviews.............................................................................................12 

 Initial Contact with Permanent Housing Programs........................................12 

 Recruitment of the Leaver Sample...........................................................12 
 

 Information Collected at Baseline and Follow-Up Conversations with Permanent 

Housing Leavers................................................................................13 

 Tracking Strategy Used to Increase Retention of Permanent Housing Leavers........14 

 Recruitment of the Stayer Sample............................................................14 

 Information Collected at Interviews with Permanent Housing Stayers.................15 
 

 Challenges the Project Faced in Participant Recruitment and Tracking................15 

iii 
 Participation and Refusal Rates of Leavers and Stayers (Baselines)....................16 

 Consumer Background Form Filled by Residential Support Staff.......................17 

CHAPTER 3: CHARACTERISTICS OF PERMANENT HOUSING PROGRAMS 

FOR PERSONS WITH SERIOUS MENTAL ILLNESS IN PHILADELPHIA, 

PENNSYLVANIA.................................................................................19 

Introduction..........................................................................................19 

Background of the Study Site: Mental Health Services and Permanent Housing..........20 

 Public Mental Health Services in Philadelphia..............................................20 

 Permanent Housing Programs for Persons with Serious Mental Illness..................21 

Characteristics of Permanent Housing for Persons with Serious Mental Illness............23 

 Definition of Permanent Housing Programs.................................................24 

Sources of Housing Subsidy...................................................................26 

Ownership of Housing Units..................................................................26 

Neighborhood Characteristics of Housing Units............................................27 

 Residential Support Services Characteristics................................................28 

 Housing Preference of Permanent Housing Residents.....................................29 

Departures from Permanent Housing: Incidence and Timing.................................31 

 Incidence of Discharges from and Admissions to Permanent Housing (Entire 

 Retrospective Sample)..........................................................................31 

 Types of Discharges from Permanent Housing..............................................32 

 Timing of Discharges from Permanent Housing for a Sub-sample of Three Entering 

Cohorts............................................................................................33 

Summary.............................................................................................34 

CHAPTER 4: LEAVING PERMANENT HOUSING -CIRCUMSTANCES 

OF LEAVING AND THE POST-PERMANENT HOUSING CAREERS OF 

LEAVERS...........................................................................................37 

Overview.............................................................................................37 

Circumstances of Leaving..........................................................................38 

 Destinations of Departure from Permanent Housing and Living Situation Upon 

Departure..........................................................................................38 

 Identification of Subgroups of Leavers – Voluntary and Involuntary Leavers..........39 

 Comparison of Voluntary and Involuntary Leavers..........................................40 

Scenarios of Leaving.............................................................................43 

Post-Permanent Housing Careers of Leavers...................................................46 

 Aggregate Profile of the Post-Permanent Housing Careers of Leavers..................47 

 Post-Permanent Housing Careers of Voluntary Leavers and Involuntary Leavers......49 

Summary..............................................................................................54 

CHAPTER 5: FACTORS ASSOCIATED WITH LEAVING PERMANENT 

HOUSING...........................................................................................55 

Overview.............................................................................................55 

Categories of Leavers..............................................................................55 

Factors Associated with Leaving and Staying in Permanent Housing- Retrospective 

Tracking Sample.....................................................................................58 

iv 
 Socio-Demographic and Diagnostic Characteristics........................................58 

 Stay History in Homeless Shelter..............................................................59 

 Service-Use Characteristics – Medicaid (CBH).............................................61 

 Service-Use Characteristics – Community Reporting System (CRS).....................62 

 Program Characteristics..........................................................................64 

 Identification of Predictors of Leaving and Staying Using Multivariate Analysis.......65 

Factors Associated with Leaving and Staying in Permanent Housing- Prospective 

Tracking Sample.....................................................................................68 

 Comparison of Socio-Demographic Characteristics between Leavers and Stayers.....69 

 Comparison of Other Individual Characteristics between Voluntary Leavers, 

Involuntary Leavers, and Stayers................................................................69 

 Levels of Skills in Independent Living and Extent of Support and Services.............70 

Summary.............................................................................................71 

CHAPTER 6: SUMMARY, IMPLICATIONS AND RECOMMENDATIONS......73 

Overview .............................................................................................73 

Summary Findings..................................................................................74 

 Characteristics of Permanent Housing ........................................................74 

 Circumstances of Leaving.......................................................................75 

 Factors Associated with Leaving Permanent Housing and Post-Permanent Careers...75 

Implications and Recommendations............................................................. 76 

APPENDIX A: GLOSSARY...................................................................A.1 

APPENDIX B: REFERENCES...............................................................B.1 

APPENDIX C: LEAVER DISCUSSION GUIDE..........................................C.1 

APPENDIX D: LEAVER FOLLOW-UP DISCUSSION GUIDE.......................D.1 

APPENDIX E: STAYER DISCUSSION GUIDE..........................................E.1 

APPENDIX F: LEAVER/STAYER CONSUMER BACKGROUND 

 WORKSHEET.................................................................F.1 

LIST OF TABLES 

Table 3.1: Capacity, Occupancy, Housing Subsidy and Homelessness................25 

Table 3.2: Current Living Situation and Preferred Living Situation 

A- With Other Mental Health Consumers.........................................30 

B- With Family Members............................................................30 

Table 3.3: Data on Current Residents, Admissions and Discharges.....................32 

Table 3.4: Types of Permanent Housing Discharges......................................33 

Table 3.5: Patterns of Discharge for Three Entering Cohorts............................34 

v 
Table 4.1: Current Residence and Living Situations at Baseline Interview After 

 Leaving Permanent Housing.....................................................38 
 

Table 4.2: Comparison of Attributes of Voluntary and Involuntary Leavers............41 
 

Table 4.3: Post-Permanent Housing Careers of Leavers- Current Residence 

 & Living Situations................................................................47 
 

Table 4.4: Post-Permanent Housing Service Use Patterns of Leavers ....................49 
 

Table 5.1: Categorization of Leavers........................................................56 
 

Table 5.2: Socio-demographic, Diagnostic and Functioning Characteristics...........59 
 

Table 5.3: Stay History in Homeless Shelter................................................60 
 

Table 5.4: Service Use Characteristics (Medicaid- CBH)................................62 
 

Table 5.5: Service Characteristics (Community Rehabilitation Services- CRS).......63 
 

Table 5.6: Program Characteristics...........................................................65 
 

Table 5.7: Multinomial Logistic Regression Results Predicting Positive Leaving, 
 

Non-Positive Leaving, and Staying in Permanent Housing...................67 
 

Table 5.8: Socio-demographic Characteristics Matched in the Study Design.........69 
 

Table 5.9: Other Individual Characteristics.................................................70 
 

Table 5.10: Level of Functioning and Extent of Support and Services...................71 
 

vi 
EXECUTIVE SUMMARY 

Background 

One principal assumption underlay the Permanent Housing component when Congress 

established the Supportive Housing Demonstration Program (and its successor, the Supportive 

Housing Program) in the Stewart B. McKinney Act: That the combination of permanent 

community-based housing and the provision of ongoing supportive services to homeless people 

with disabilities would foster among individuals of that difficult-to-serve population the greatest 

independence or self-sufficiency possible. A similar concept underlies the Shelter Plus Care 

(S+C) program established by the National Affordable Housing Act of 1990. The purpose of 

S+C was to “provide rental housing assistance, in connection with supportive services funded 

from other sources other than this subtitle, to homeless persons with disabilities (primarily 

persons who are seriously mentally ill, have chronic problems with alcohol, drugs, or both, or 

have acquired immunodeficiency syndrome and related diseases) and the families of such 

persons.” The third programmatic HUD McKinney-Vento Act permanent housing alternative, 

although not specifically targeted to a disabled homeless population, does serve a high 

proportion of homeless people with serious mental illness; in 2001, for example, roughly a third 

of all adults entering HUD-supported Single Room Occupancy (SRO) units were mentally ill. 

Permanent housing has remained a major focus of the Department’s programs that specifically 

serve homeless people with disabilities. The combined funding for HUD McKinney-Vento Act 

programs (including the Emergency Shelter Grant (ESG), Supportive Housing, S + C and 

Section 8 SRO programs) that contain no limits on length of stay, S + C, Section 8 SRO and the 

Permanent Housing component of the Supportive Housing Program, has over the lives of those 

programs made up approximately a third of all funding ($3.2 billion of $9.8 billion). Although 

the proportion of funding going to these three permanent housing programs has varied 

considerably from year to year, ranging from 17 percent in 1997 to 70 percent in 1993, the 

Department has responded to clear Congressional direction to keep the permanent housing option 

at the forefront of HUD’s homeless efforts, and approximately 45 percent of its funding effort 

(including the non-competitive and short length of stay ESG program) went to permanent 

housing in FY 2004. 

Yet there is considerable difference between the presumption of long-term housing and 

supportive services as the key to moving homeless people with disabilities toward the greatest 

self-sufficiency of which they are capable and the realities of length of stay in HUD-assisted 

permanent housing for homeless people with disabilities. For example, according to the Annual 

Progress Report (APR), the annual reporting document for HUD-funded competitive homeless 

programs, about five percent of all adult participants of HUD-funded permanent housing for the 

homeless (including the Permanent Housing Program, the S + C Program and the Section 8 SRO 

Program) during program year 2004 left within the first two months after entry; another seven 

percent left in the period from three to six months; and altogether about a quarter of all 

vii 
Permanent Housing beneficiaries throughout that year left after two or fewer years in the 

permanent housing setting. For some significant number of homeless people with disabilities, 

McKinney Act-supported permanent housing is apparently not experienced as permanent. 

When the homeless providers who are recipients of HUD homeless funding reported, where 

known, the destination of adult participants who departed permanent housing, 23 percent were 

reported as going directly to market-rate rental housing, 29 percent to subsidized rental housing 

and one percent to homeownership situations. On the other hand, there was a sizable proportion 

whose destinations were less propitious. For example, 20 percent were moving in, either 

permanently or on an interim basis, with families or friends; ten percent were going to 

jail/prison, a psychiatric hospital or an inpatient alcohol or drug treatment facility; three percent 

departed for transitional housing, three percent to emergency shelters and one percent back to the 

street. 

These figures raise very important policy questions for the Department in its administration of its 

permanent housing programs for homeless persons. For example: 

1.	 What does permanent housing mean for homeless providers and clients? What gives 

HUD-funded permanent housing its distinctive character, if anything? Or is it simply a 

form of housing that permits long-term residency but in practice looks like transitional 

housing but for a narrower eligible population? 

2.	 What happens to the formerly homeless people with disabilities who leave HUD-funded 

permanent housing? How do they differ from those who remain in the HUD-funded 

permanent housing? Why do those who depart leave? Where do they go? How do they 

fare? What happens to them over time? What do their post-permanent housing 

residential careers look like? 

3.	 How does the degree and nature of disability and the length of time without housing at 

the time participants enter permanent housing affect how long they remain in the 

permanent housing, where they go upon departure and housing stability after leaving 

permanent housing? Do people who leave permanent housing voluntarily have 

significantly different residential careers after permanent housing than those who leave 

involuntarily? Does length of stay in permanent housing affect significantly the 

residential careers of residents of permanent housing after they leave that housing? Does 

the composition of the services offered and the timeframe within which the services are 

provided in the permanent housing affect significantly the residential careers of 

permanent housing leavers once they depart that housing? 

This research is primarily but not exclusively about homeless people with serious mental illness. 

It is clear that early availability of HUD McKinney Act funding for permanent supportive 

housing coincided with actions by the City of Philadelphia and the State of Pennsylvania to close 

Philadelphia State Hospital in the early 1990s and to restructure public mental health care in the 

city (See Chapter 3). Philadelphia has since been markedly successful in capturing Supportive 

Housing and S + C Program dollars for permanent supportive housing, $92 million from 1987 to 

2004. Moreover, the 28 permanent housing providers involved in this study reported that more 

viii 
than 60 percent of their current residents had previously been homeless, and ten of those 

providers reported that 70 percent or more of their current clients had been homeless prior to 

entry. However, the administrative data upon which a significant part of the analysis is based 

does not identify permanent housing residents by source of funding. As such, this study and its 

findings pertain to permanent housing in general in Philadelphia and do not necessarily represent 

HUD McKinney Act permanent housing projects. In effect, we are constrained in our ability to 

isolate the formerly homeless mentally ill population from the larger group of lower income 

mentally ill population for much of the analysis. 

Method 

In 2002, the Department of Housing and Urban Development’s Policy Development and Research 

Office contracted with M. Davis and Company, Inc. and University of Pennsylvania’s Center for 

Mental Health Policy and Services Research to undertake a research project to help answer these 

questions. Philadelphia was selected as the study site, in part, because it has one of the most 

comprehensive Homeless Management Information Systems (HMIS) in operation in the nation. 

In addition, the University of Pennsylvania has developed a strong and continuing working 

relationship with the City and the State of Pennsylvania that permits analysis of longitudinal 

administrative data for individuals served by, among others, the health, mental health, welfare and 

criminal justice systems of the City, County and State. 

The HMIS enabled the study to incorporate a multi-modal tracking strategy. The strategy included 

two components: (1) retrospective tracking of 943 mentally ill individuals who ever stayed in 

permanent housing between January 1, 2001 and July 15, 2004, using an integrated longitudinal 

administrative database, and (2) prospective tracking via interviews of 100 leavers who left 

permanent housing from February, 2003 to December, 2004 and a matched sample of 96 stayers 

who were current permanent housing residents as of January, 2005. The selection of both the 

retrospective and prospective samples was designed to maximize the use of the integrated 

longitudinal database available at the study site and facilitate a workable strategy to track 

permanent housing leavers over an 18-month or greater period and to secure reliable information 

on post-permanent housing residential careers. The study also included interviews with 

permanent housing support team providers, and secondary data analysis of a survey of permanent 

housing residents and support team providers, funded by the National Institute of Mental Health 

(NIMH). 

Findings 

Permanent housing embraces a variety of approaches that differ in housing and service 

characteristics. When referencing characteristics of permanent housing, it is important to include 

or, minimally, be aware of, the characteristics of importance to residents, features such as 

condition/maintenance and location of the residence, staff involvement/relationship with 

residents and presence of “problem/non-compliant” tenants. These “characteristics” are 

subjective, particularly the latter two; however, they are of clear significance to tenants. The 

unifying feature of permanent housing is the provision of housing subsidy with no stay limit 

ix 
attached to program participation. Although we can conclude that permanent housing is a longterm housing arrangement for a significant portion of permanent housing residents, it is evidently 

not a “permanent” housing arrangement for many others. In fact, many permanent housing 

residents do not expect that their residency in permanent housing will be permanent. 

For leavers who have favorable post-permanent housing careers their limited tenure in permanent 

housing could be interpreted as a positive outcome. These leavers have moved to living 

situations that require more independence than permanent housing. In essence, they are on a 

track to be permanently off the street and integrated into the community. However, there is a 

discernible proportion of leavers for whom permanent housing is neither a long-term solution nor 

assists them in reaching a long-term solution. Clearly, for these homeless persons permanent 

housing is not the end of their distress because they leave and go to unstable or less positive 

housing settings or return to the street. This study will help to better understand why this is 

occurring, what characteristics of the permanent housing or participants lead to leaving and what 

shape the lives of leavers take once they depart permanent housing. 

Housing Tenure of Permanent Housing Residents 

Although it may be said that permanent housing for homeless people with disabilities is a longterm housing arrangement for a significant portion of permanent housing residents, this study 

suggests it is not a “permanent” housing arrangement for everyone. Analysis of three permanent 

housing entry cohorts between 2001 and 2003 in Philadelphia indicates that a significant portion 

of residents entering permanent housing at the same time left before two years of residence. If 

the discharge patterns of the 2001 cohort were representative of all permanent housing residents, 

then we may expect that only half of those entering permanent housing would be able to keep 

their residency for three years or more. More than ten percent, in fact, left within six months, 

and nearly a quarter left within the first year after entry. There is no basis upon which to adjudge 

the length of stay of study cohorts in Philadelphia different than that of permanent supportive 

housing residents elsewhere. 

It is also noteworthy that the experience of leaving permanent housing is not limited to those 

who have relatively short tenure in permanent housing. Indeed, leaving also happened among 

permanent housing residents who might be considered most stably housed, that is, individuals in 

the same permanent housing program for many years. In illustration, 41 percent who had 

entered permanent housing units in the city before 1999 left in the period between 2001 and 

2003. 

Leaving, it should be noted, may not be an adverse outcome; for some clients, leaving is a 

desirable event that leads to better housing or to a higher level of independence and selfsufficiency. For example, over 18 percent of those discharged during the three years of the study 

reported as living independently and alone. Another three percent were living with a spouse or a 

significant other. 

x 
Differences between Those Who Leave Permanent Housing and Those Who Stay 

Findings from the integrated longitudinal data identify no differences between leavers and 

stayers along major demographic attributes, including age, gender, race/ethnicity, psychiatric 

diagnosis, substance treatment history and level of functioning as rated by the Global 

Assessment of Functioning (GAS) scale – a simple standardized rating scale of the current 

overall level of functioning of the client. Moreover, characteristics of permanent housing 

programs measured at the residential support team level, including program size (capacity) and 

provider-assessed level of functioning and intensity of support, are not associated with leaverstayer status. 

In contrast, individual behavioral health services use, particularly service use during participants’ 

stays in permanent housing, emerges as a key factor predicting leaving and staying in permanent 

housing. Specifically, leavers as a group are more likely than stayers to have experienced 

inpatient mental hospital admissions, more likely to have used community residential services, 

and more likely to have used emergency services during their tenure in permanent housing. 

Stayers, on the other hand, had more contact with community residential services prior to 

permanent housing entry and more contact with outpatient services during their permanent 

housing stay. The significantly higher incidence of psychiatric hospitalization and emergency 

services use among leavers could be indicative of the deteriorating status of mental health among 

leavers after entering permanent housing. Experiences of relapses may be an important factor 

contributing to the inability of some permanent housing residents to continue their tenure in 

permanent housing. 

Categories of Those Leaving HUD-Funded Permanent Housing 

Furnished with information about the whereabouts of leavers in both the integrated longitudinal 

data and the interview data, we distinguished between two subgroups of leavers. In summary, 

one-third of the leavers are designated as “positive leavers” who left permanent housing to go to 

independent and other living arrangements (such as with family and friends)1 that are not 

associated with professional residential support, and two-thirds are designated as “non-positive” 

leavers who left permanent housing to go to congregate residential settings (in general, a more 

intensive residential support than permanent housing), institutional settings (hospitals and 

correctional institutions), homelessness, and other unspecified whereabouts. This finding is 

based on the “discharge codes” assigned in the administrative data at the point of departure. 

1 We acknowledge throughout this report that departing to family and friends is characterized as a positive departure 

in some results and non-positive in others. Use of variant data sources has necessitated more ambiguity in this 

regard than certainly is preferable. Departure to family and friends can represent a very temporary circumstance for 

some and a permanent solution for others. For some formerly homeless people with serious mental illness, the 

relative independence of moving in with family and friends is a sign of capacity; for others, it may be an 

acknowledgement of dependence. Differing data elements and presumptions of the various data sources used in this 

report do not always allow us to make those kinds of distinctions. We do, however, indicate in each instance what 

departure to family and friends means with that context. 

xi 
Similarly, based on the reports of leavers and residential support staff in the interview data, we 

found two major subgroups of leavers: voluntary leavers (61%) and involuntary leavers (39%). 

Voluntary leavers are residents who elected to leave permanent housing to either pursue better 

housing or to move away from problems they experienced at their current permanent housing 

program. Involuntary leavers are residents who have been asked to leave the permanent housing 

because they violated program rules, such as drinking and using illicit drugs at their apartment, 

or program staff considers them incapable of maintaining themselves in a supportive permanent 

housing environment. 

Although it is questionable whether the two aforementioned classifications are sufficiently 

refined to capture the variety among leavers and the dynamics of leaving, the findings derived 

from these classifications point to an interesting observation—that is, leaving as an overarching 

category may not be very meaningful. Based on the comparison between “positive” and “nonpositive” leavers, as well as “voluntary” and “involuntary” leavers, we found noteworthy 

differences among leavers: 

1.	 There are no differences between positive and non-positive leavers in terms of sociodemographic characteristics, psychiatric diagnosis, and level of functioning, all measures 

taken before leavers entered permanent housing. Neither was there any difference in 

length of stay in permanent housing between those two subgroups of leavers. 

2.	 There was also no discernable difference between positive and non-positive leavers in all 

measures of service use prior to entering permanent housing. The lack of difference 

includes use of homeless shelters. 

3.	 Non-positive leavers consistently reported higher levels of service use than positive 

leavers during their stay in permanent housing. Statistically significant differences 

between the two groups include psychiatric hospitalization, use of day treatment 

programs and use of emergency services during their permanent housing stays. 

4.	 Non-positive leavers consistently reported higher levels of service use than positive 

leavers subsequent to their discharge from permanent housing. Statistically significant 

differences between the two groups include shelter use, intensive case management 

(ICM) services, ambulatory services, psychiatric hospitalization, community residential 

services and emergency services. 

5.	 A significant minority of non-positive leavers experienced homeless shelter use (26%) 

and psychiatric hospitalization (24%) subsequent to leaving permanent housing. This 

contrasts with the very low percent of homelessness (3%) and institutionalization (5%) 

reported from the discharge codes given at the time of leaving. In contrast, only 10 

percent of positive leavers reported use of homeless shelters, and 15 percent reported 

psychiatric hospitalization. 

6.	 Based on the assessment of residential support staff, involuntary leavers experienced 

more behavioral problems, demonstrated lower level of independent living skills, and 

received more intensive support than voluntary leavers. 

xii 
As it works out, those permanent supportive housing residents who are most “at risk” are 

involuntary leavers who have a drug/alcohol relapse or are non-compliant with 

permanent housing rules. These residents tend also to be most costly to serve during their 

post-permanent housing career. Although a smaller proportion of involuntary leavers use 

emergency services after their permanent housing stays than do during their permanent 

housing stays, their use of emergency services is more than three times greater than 

positive leavers. 

Additionally, use of vocational/social rehabilitation services predicts tenure in permanent 

housing. Leavers are less likely than stayers to use such services both before and during 

permanent housing stays. Moreover, it is noteworthy that the survey data did 

differentiate between “voluntary” and “involuntary” leavers. Program staff assessments 

revealed that voluntary leavers overall had a higher level of functioning and lower need 

of assistance than stayers. Conversely, involuntary leavers were reported to have a lower 

level of functioning and higher need of assistance than stayers. 

7.	 Comparison between voluntary leavers, involuntary leavers, and stayers indicates that 

voluntary leavers are more similar to stayers in behavioral characteristics, independent 

living skills and needs for services than to leavers. Indeed, for a number of measures, 

voluntary leavers were reported to have higher level of skills and require less intensive 

services than stayers. 

In summary, notwithstanding the lack of comparability between the two methods of categorizing 

leavers using integrated longitudinal and interview data, it is evident that an important distinction 

can be made between permanent housing residents who left because of unfavorable conditions 

and those who left demonstrating their capability for a higher level of independence. 

Circumstances of Departure from HUD-Funded Permanent Housing 

Involuntary leavers, voluntary leavers who departed seeking opportunities, and voluntary leavers 

who moved in order to avoid problems (that is, those whom we designate as situational leavers) 

in general left permanent housing under different circumstances. Among these three groups, the 

opportunity seekers reported the most favorable circumstances for leaving permanent housing. 

They categorized their leaving as a form of graduation from permanent housing to a housing 

setting that they perceived was an improvement. These leavers “graduated” from permanent 

housing, frequently with a housing subsidy (for example, Section 8), demonstrated a high level 

of independent living skills, were assessed by residential support staff as not needing residential 

support services upon departure and were regarded as capable of participating in a program with 

a minimal level of program requirements (such as moving from a clustered site program to a 

scattered site program). It should be noted that voluntary leavers who “graduated” to subsidized 

housing without residential support often continue to use other mental health system supports 

such as outpatient and case management services. Clearly one important finding of this study is 

that leaving permanent housing is not necessarily a negative outcome. The fact that clients 

“move on” to other even more “normal housing” arrangements is not a reflection of a failure of 

xiii 
the system but of the success of the client. This is consistent with the recent focus on “recovery” 

for persons with serious mental illness. This model emphasizes the process of recovery over 

time so that clients are less dependent on the care system and more able to integrate into the 

housing market. The assumption that clients will always need the financial and social supports of 

permanent housing is just not consistent with what we know about the lives of persons with 

serious mental illness. 

“Situational leavers” elected to leave permanent housing to avoid or overcome problems they 

encountered in their personal, housing and support situations. Some situational leavers left 

permanent housing because of the demolition of their housing site. While transitioning to 

another housing site or facility may pose challenges for these leavers, the predicaments they 

faced tended to be transient and perhaps could have been resolved with additional support from 

the residential staff and other mental health providers. In contrast, the departure of other 

situational leavers was due to deteriorating functioning status and/or their preference for more 

structure and services in their living arrangements. In such situations, provided that appropriate 

alternative living arrangements were available, departures from permanent housing among 

problem leavers could be considered a “positive” move. 

As one would expect, the circumstances surrounding departure offered by involuntary leavers 

represent a more formidable concern for policymakers, service providers, and housing 

developers. Drug and alcohol use, failure to follow program rules and regulations, inability to 

manage one’s own medication, and exhibition of dangerous behavior are some of the 

precipitating factors mentioned by both involuntary leavers and their service providers. 

These unfavorable circumstances may indicate a mismatch between the functioning status of 

some permanent housing residents and the level of independence required in some permanent 

supportive housing settings. Moreover, some of the “complaints” from involuntary leavers 

regarding the stringency of program rules highlight the possible dissonance in expectations 

between permanent housing residents and support staff. The quality of resident-staff 

relationships may be an important factor predicting adverse outcomes of permanent housing 

residents. Finally, it is important to note that some involuntary departures may be attributable to 

external factors that cannot be controlled by permanent housing residents. For example, some 

involuntary leavers cited drug activity in their buildings and neighborhoods as a factor 

aggravating their substance use problems, leading to a downward spiral of relapse and, 

eventually, to discharge from permanent housing program. 

Leavers could also be categorized by the level of independence afforded by the destinations to 

which they departed. Under this categorization, one-third of the leavers could be designated as 

“independent-housing leavers” who left permanent housing to independent living arrangement 

and other living arrangements (such as with family and friends) that are not associated with 

residential support. Another one-third of leavers would be designated “non-independent-housing 

leavers” who left permanent housing for either housing situations with more intensive residential 

support than permanent housing and institutional settings including homeless shelters, hospitals 

and correctional institutions. The remaining category includes those who departed to other or 

unspecified locations. 

xiv 
Post-Permanent Housing Residential Careers of Leavers 

The post-permanent housing residential careers of leavers are closely related to the 

circumstances under which they left the permanent housing. As might have been expected based 

on the findings above, voluntary leavers are more likely to have stable post-permanent housing 

residential careers; they tended to live where they moved when they left permanent housing in 

the first place. Involuntary leavers, are more likely to have experienced residential instability; 

some involuntary leavers, in fact, do make their way back to permanent housing after several 

episodes of homelessness or more or less continuous stays in shelters. In addition to 

homelessness, involuntary leavers are more likely to have experienced stays in drug/alcohol 

treatment facilities and to have been hospitalized for psychiatric problems during their postpermanent housing residential careers. Aside from better residential outcomes, voluntary leavers 

tend to report lower housing costs than involuntary leavers. This might in part be explained by 

evidence that suggests that voluntary leavers are more successful in obtaining and retaining 

subsidized housing. 

Analysis of post-permanent housing residential careers suggests that most leavers, regardless of 

their current residence, expressed relative satisfaction with their quality of life. The most 

prominent advantages of leavers’ post-permanent housing careers, as expressed by the leavers 

themselves, are the sense of independence they feel in their new surroundings; the opportunity to 

work or to work more hours; the peaceful environment where they can “focus”; the ability to 

accommodate family; and the benefits of good location, convenience, and safety. The most 

prominent disadvantages of their current situations were drug activity in the building and 

neighborhood; persistent worry about eviction; and problems relating with neighbors. 

Implications and Recommendations 

The findings from this research suggest that departure from permanent housing is a complex 

phenomenon. Simple dichotomization of “leavers” and “stayers” is simply not sufficient to 

guide public policy in enhancing the effectiveness of permanent housing. In this project, 

departure from permanent housing was categorized according to the circumstances under which 

residents left permanent housing and by the destinations to which leavers were discharged. A 

substantial proportion of leavers moved to residences that required more independent living 

skills and less reliance on supportive services than the permanent housing program they left. 

These outcomes certainly underscored that a “leave” cannot be categorized as negative. 

However, regardless of the criteria used, a significant portion of leavers from permanent 

supportive housing depart under unfavorable circumstances, are discharged to homeless or 

institutionalized settings or to community residential settings requiring higher level of 

supervision and care. One action response to this finding is to identify the risk factors associated 

with unfavorable departures from permanent housing and to design permanent housing practices 

and programs that respond to those risks. 

xv 
Based on the integrated longitudinal data analyzed here, basic socio-demographic characteristics 

and generalized measures of level of functioning (such as the Global Assessment of Functioning) 

taken at the point of entering permanent housing do not effectively distinguish among stayers, 

leavers who depart under favorable circumstances, and leavers who depart under unfavorable 

circumstances. The “crude” nature of the assessment instruments may explain some of this lack 

of differentiation, particularly with regard to the measures for level of functioning and 

“capability of independent living.” If real differences exist at intake but are not detected, more 

thorough assessment procedures should be introduced to identify which homeless individuals 

would benefit from various combinations of housing and support services. 

The findings from this project suggest that service use during residents’ tenure in permanent 

housing may turn out to be one of the most important predictors of either staying in permanent 

housing, leaving under favorable conditions or leaving under unfavorable conditions. As both 

the behavioral health service use administrative data and the interview data show, leavers who 

departed permanent housing under unfavorable circumstances were assessed by their residential 

support staff as having lower levels of independent living skills and requiring higher level of 

assistance and support. This finding is supported by the integrated longitudinal data, which 

indicate that “unfavorable” leavers were more likely to use ambulatory services (including 

intensive case management) and community residential services during their tenure in permanent 

housing. 

The use of community-based behavioral health services aside, perhaps the most striking finding 

is the disproportionate use of homeless services, in-patient psychiatric services and emergency 

psychiatric services among leavers who did not fall within the category of positive discharges. 

The evidence of relapse experienced by leavers who departed permanent housing under 

unfavorable circumstances as indicated by hospitalization, return to homeless shelters, and use of 

emergency services, highlights the importance for residential support staff to recognize the 

“early warning signs” of potential “failure” in permanent housing. The challenge is for mental 

health support staff to develop and implement an effective intervention plan to help permanent 

housing residents who are at risk of “failing” in permanent housing due to relapse. It should be 

noted here that for permanent housing residents whose relapses are temporary, returning to the 

permanent housing program should be the intervention goal. But for those whose relapses 

represent an irreversible deterioration of functional and psychiatric status, placement in 

community residential settings with more structure and/or a higher level of supervision should be 

regarded as a successful exit from permanent housing. 

The scenarios for leaving gleaned from the interview data reveal two sets of program-level 

characteristics and highlight the importance of environmental factors that may affect the 

likelihood of success among permanent housing residents. Housing environmental factors, 

including the extent of crime and illicit drug activity in the building and neighborhood, were 

mentioned by leavers as affecting their chance of staying sober and their capacity to manage 

stress, and consequently, their ability to stay in permanent housing. In contrast, leavers who 

appear to be successful in their post-permanent housing careers time and again cited the 

desirability of their housing and neighborhoods as helping them to stay “focused” and to avoid 

stressful situations. Accounts of adversarial relationships between residential support staff and 

resident, and inability to follow program rules, on the other hand, also emerge as precipitating 

xvi 
factors in a number of scenarios involving involuntary leaving. Importantly, both the housing 

characteristics pertaining to buildings and neighborhoods, as well as the support characteristics 

pertaining to resident-staff relationship and program rules, are factors that could potentially be 

modified to increase the duration of permanent housing stays and enhance the quality of life of 

permanent housing residents. Although this study did not find statistically significant impact for 

environmental factors this may be due to the fact that the data sets available to the researchers 

were too limited or too insensitive to reveal the effects. It is important to note that in the client 

interviews environmental factors were often mentioned by clients as important reasons for 

leaving or staying in permanent housing and further research in this area may be useful. 

Based on the above conclusions and implications, the following recommendations are offered to 

improve the outcomes of permanent housing programming: 

•	 Permanent supportive housing should continue to be a centerpiece of Federal 

government’s effort to help end homelessness. Consistent with the literature and 

reflective of the data, permanent housing is the “housing of choice” for homeless 

mentally ill persons. Rent subsidies provided as part of the permanent housing 

arrangement enable residents to have access to resources, thereby enhancing their quality 

of life. 

•	 Thorough assessment procedures should be used to match the support needs and 

preferences of permanent housing residents, as well as levels of independent skills among 

prospective permanent housing residents. Some evidence from recent literature indicates 

that even some people who experience chronic street homelessness can maintain 

independent housing with support from staff and with a minimal level of program 

requirements (Pathways in NYC, Tsemberis 1999; Tsemberis et al. 2003) if services and 

housing are tailored to the combination of needs and preferences of consumers. Recent 

data suggest that these clients may require significantly more support but additional 

research needs to be conducted on the effectiveness of the Housing First Model for 

particular populations and about which features of Housing First are essential and which 

are optional. 

•	 Additional evaluations of clients should at least be conducted at two points: (1) when 

clients are seeking or accepting permanent housing and (2) when prospective leavers are 

seeking independent housing. These are two points at which the program may have its 

greatest leverage to influence a client’s participation in supportive services or 

interventions designed to help the client sustain his/her permanent housing and/or achieve 

a stable residential career. 

•	 An array of permanent housing programs is required to match the diverse needs and 

preferences of homeless mentally ill persons and the extent of structure and supervision 

that consumers need. Philadelphia’s experience may offer an example in this regard, 

whereby, over time, the City’s Office of Mental Health has diversified its housing 

offerings by converting traditional community residential rehabilitation programs that 

had moderate to maximum levels of supervision, into more independent strands of 

permanent supported housing. As permanent housing, these converted units offer 

xvii 
clustered apartments, often with peer support from consumers. Along with other 

permanent housing and Community Rehabilitation Residence programs, this housing 

stock offers a broad array of options for maximizing the goodness of fit between 

consumers and housing options. 

•	 Housing agencies should create “early warning systems” to identify permanent housing 

residents at risk for unfavorable discharges. Hospitalizations, arrests, eviction warnings, 

or behavior that places a resident at risk of these events should trigger an intervention by 

the placement agency, housing agency, and support service staff. Upon such an event, an 

assessment should be made of the appropriate resident or support staff adaptations that 

could be made to ensure stability of a given placement, or of the alternative settings in 

which a resident should be placed. Clear protocols should be established which outline 

when and what proactive action should be taken at the time of resident-staff conflict or 

when residential instability is otherwise indicated. 

•	 The non-positive outcomes and greater cost to serve involuntary leavers suggest 

undertaking further analysis to determine if there is justification to develop permanent 

housing specifically designed for repeat drug/alcohol abusers. Permanent housing 

residents “at risk” are often involuntary leavers who have a drug/alcohol relapse or are 

non-compliant with permanent housing rules. These residents are costly to serve during 

their post-permanent housing career. Although a smaller proportion of involuntary 

leavers use emergency services post-permanent housing than during their permanent 

housing-stay, their use of emergency services after departure is still more than three times 

greater than that of positive leavers. 

•	 The provision of residential support services needs to be recognized as critical and 

integral components of permanent housing. Provision of a long-term housing subsidy is a 

necessary but not sufficient condition for success. Permanent housing residents have 

substantial physical and behavioral health needs for which appropriate and continuous 

support is critical to maintain independent living. 

•	 Careful consideration should be made as to the location of permanent housing and should 

avoid placing permanent housing residents in neighborhoods with high crime rates and 

drug activities that inadvertently increase the risk of relapse for residents. Housing 

developers and residential support staff should also work hand-in-hand in order to 

improve the building environment (lessen the risk of alcohol/drug activities) and to 

provide a favorable environment for the recovery of consumers. 

•	 The Federal government’s effort to end chronic homelessness should include as an 

objective the re-engagement of homeless persons with SMI who left permanent housing. 

Continuum of Care application requirements could encourage re-engagement of such 

persons as a priority in funding decisions. The development of Homeless Information 

Management Systems (HMIS) for tracking homeless persons both in shelters and in 

permanent housing is a strong movement in the right direction, as such a system could 

theoretically enable a jurisdiction to identify people upon shelter admission who might 

meet this criterion. 

xviii 
•	 Research on the long-term outcomes of involuntary and voluntary leaving should refine 

the characterization of post-permanent housing careers over a longer period than the 12 to 

24 months possible in this study. That kind of research will demand new and imaginative 

forms of tracking and engagement of people with serious mental illness who may not be 

using the services that are publicly available. 

•	 Initiatives to help end homelessness should accommodate the desire by many current 

permanent housing residents to live in more independent housing. Permanent housing 

can accommodate this need via, for example, different configurations of support 

reflective of the current service utilization by leavers in their post permanent housing 

career. There are numerous benefits that can accrue from this progression including: 1) 

those who leave permanent housing are less reliant on federal and local resources and 

sometimes achieve total independence from services designated for formerly homeless 

persons, 2) the newly available resources are available to others, and 3) permanent 

housing “graduates” may be available to mentor current PH residents who aspire to be 

more independent. 

xix 
xx
 
CHAPTER 1: INTRODUCTION AND OVERVIEW OF THE STUDY 

Introduction 

Since passage of the Stewart B. McKinney Homeless Assistance Act in 1987, the provision of 

permanent housing with supportive services has been a major focus of the federal response to the 

needs of homeless people with disabilities. The long-term goal of the U.S. Department of 

Housing and Urban Development (HUD)’s homeless effort is based on the assumption that 

permanent community-based housing, coupled with supportive services, would foster the 

greatest stability, independence and self-sufficiency possible among formerly homeless 

individuals who are chronically disabled. 

Although there is evidence that permanent housing reduces homelessness and improves housing 

stability among program participants (Ridgway and Rapp 1998), data from two national 

evaluations of HUD-funded permanent housing programs (Matulef et al. 1995; Fosburg et al. 

1997) and the Department’s Annual Progress Report (APR) suggest that housing tenure is 

neither permanent nor even long-term for a significant minority of program clients. Of particular 

concern is the supposition based on APR data that only half of permanent housing leavers depart 

for “ideal” housing situations (such as other subsidized rental housing, market-rate rental 

housing, and homeownership), and that the other half of leavers either share accommodations 

with relatives and friends, go to a jail, a psychiatric hospital, or a treatment facility, or return to 

the street and homeless shelters subsequent to departing from permanent housing. 

The reality of limited tenure in HUD-assisted permanent housing for some portion of program 

participants raises important questions about the nature of HUD-assisted permanent housing 

programs and about the participant and program characteristics that predict leaving or staying in 

permanent housing. Moreover, understanding the circumstances surrounding departure from 

permanent housing and the post-permanent housing residential careers of leavers should help 

policymakers and practitioners to develop strategies to identify program participants who are not 

yet ready to move on to more self-sufficient housing situations and thus to avoid undesirable 

exits from permanent housing. 

The present research effort was designed to address an important set of questions about the 

departure of previously homeless people with disabilities from permanent housing and their postdeparture residential careers. Identifying the reasons for leaving permanent housing should 

inform policy and planning relating to chronic homelessness among people with disabilities. To 

this end, this project examined the phenomenon of departure from permanent housing from the 

following perspectives: 

•	 The distinctive characteristics of permanent housing programs 

•	 The circumstances of leaving and the post-permanent housing careers of leavers 

•	 The factors associated with leaving permanent housing and post-permanent housing 

careers 

1 
Background 

HUD-Assisted Permanent Housing 

When Congress established the Stewart B. McKinney Homeless Assistance Act in 1987, the 

Secretary of the Department of Housing and Urban Development, in creating the Supportive 

Housing Demonstration Program (SHDP), was instructed to “carry out a program in accordance 

with the provisions of this subtitle to develop an innovative approach for providing supportive 

housing, especially to deinstitutionalized homeless individuals, homeless families with children, 

and homeless individuals with mental disabilities and other handicapped homeless persons.” 

The Conferees who met to arrive at common legislative language between the House and the 

Senate included the provision for housing for the handicapped homeless to supplement the 

transitional housing component that had been in both the Senate and House bills. In the words of 

the Conference Report: 

“This program [the Permanent Housing for Handicapped Homeless Persons program proposed in 

the House bill] would have enabled States to provide nonprofit organizations with grants to 

finance the acquisition and rehabilitation of property to serve as permanent community-based 

housing for handicapped homeless persons ... The Conference report combines the Transitional 

Housing Demonstration Program and the proposed Permanent Housing for the Handicapped 

Homeless Persons with the Supportive Housing Demonstration Program. The Conferees 

emphasized that a central purpose of the SDHP is to meet the needs of deinstitutionalized 

homeless persons and persons with mental disabilities ... The Conferees recognize that 

deinstitutionalized homeless persons and other persons with mental disabilities are among the 

most difficult segments of the homeless population to serve and, therefore, intend that special 

consideration be given to projects designed to meet their needs so that such projects will receive 

a significant share of the funding made available under this program. 

The presumption underlying the Permanent Housing Program, then, was that the combination of 

permanent community-based housing and ongoing supportive services to homeless people with 

disabilities, many of them psychiatric in nature, would foster the greatest independence and selfsufficiency possible. A similar concept underlies the Shelter Plus Care (S+C) program established 

by the National Affordable Housing Act of 1990. The purpose of S+C was to “provide rental 

housing, in connection with supportive services funded from other sources other than this subtitle, 

to homeless persons with disabilities (primarily persons who are seriously mentally ill, have 

chronic problems with alcohol, drugs, or both, or have Acquired Immune Deficiency Syndrome 

and related syndromes) and families of such persons.” 

The third HUD funded permanent housing program for homeless persons is the Section 8 Single 

Room Occupancy (SRO) program. Under the program, HUD enters into Annual Contributions 

Contracts with public housing agencies (PHAs) in connection with the moderate rehabilitation of 

residential properties that, when rehabilitation is completed, will contain multiple single-room 

dwelling units. These PHAs make Section 8 rental assistance payments to participating owners 

(that is, landlords) on behalf of homeless individuals who rent the rehabilitated dwellings. 

Section 8 SRO residents in the aggregate share many of the special needs of residents of 

permanent housing and S+C projects. For example, of all adults entering Section 8 SRO housing 

2 
during 2001, 33 percent were reported by homeless providers to be affected by mental illness, 32 

percent affected by alcohol abuse and 38 percent, drug abuse. The comparable proportions were 

56 percent, 35 percent and 40 percent, respectively, for permanent housing program participants 

and 58 percent, 35 percent and 39 percent for S+C program participants. The principal 

difference is the high proportion of homeless people with mental illness in permanent housingand S+C- supported units. 

Since the establishment of Stewart B. McKinney Homeless Assistance Act in 1987, permanent 

housing has been a major focus of HUD programs that specifically serve homeless people. The 

combined funding for the Department’s McKinney-Vento Act programs (including Emergency 

Shelter Grant, Supportive Housing, S+C, and Section 8 SRO programs) that contain no limits on 

length of stay, S+C, Section 8 SRO and the Permanent Housing component of the Supportive 

Housing Program, has over the lives of those programs made up approximately a third of all funding 

($3.2 billion of $9.8 billion). Although the proportion of funding going to these three permanent 

housing programs has varied considerably from year to year, ranging from 17 percent in 1997 to 70 

percent in 1993, the Department has responded to clear congressional direction to keep the 

permanent housing option at the forefront of HUD’s homeless efforts, and approximately 45 percent 

or more of its funding effort (including the noncompetitive and short length of stay Emergency 

Shelter Grant (ESG) program) went to permanent housing in FY 2004. 

Limited Length of Stay for Participants of Permanent Housing Programs 

According to the APR, the annual reporting document for HUD-funded competitive homeless 

programs, about five percent of all adult participants of HUD-funded permanent housing for the 

homeless (including the Permanent Housing Program, the S+C Program and the Section 8 Single 

Room Occupancy Program) in program year 2004 left within the first two months after entry; 

another seven percent left in the period from three to six months; and nearly a quarter of all clients 

left within two years of entry. It appears that for many homeless people with disabilities, McKinney 

Act-supported permanent housing is not experienced as permanent. 

When the homeless providers who are recipients of HUD homeless funding reported the destination 

of adult participants who departed permanent housing, 23 percent were reported as going directly to 

market-rate rental housing, 29 percent to subsidized rental housing and one percent to 

homeownership situations. On the other hand, there was a sizeable proportion whose destinations 

were less propitious. For example, providers reported that 20 percent of those departing were 

moving in, either permanently or on an interim basis, with families or friends; 10 percent were going 

to jail/prison, a psychiatric hospital or an inpatient alcohol or drug treatment facility, three percent 

departed for transitional housing, three percent to emergency shelters and one percent back to the 

street. 

For most of those leaving HUD-funded permanent housing, their sets of benefits had not changed 

from the time they entered until they exited permanent housing; however, overall more people 

reported having an income after entering permanent housing. The percentage of all adult participants 

who left HUD-funded permanent housing projects and who had income increased from 12 percent at 

entry to 21 percent at departure; conversely, the percentage of people who left and who had no 

3 
financial resources declined from 29 percent at entry to 16 percent at departure. Other than that, the 

percent with other benefits, including mainstream social programs, increased minutely, if at all, from 

entry to departure. 

There have been only two formal evaluations that have looked at HUD-funded permanent 

housing for homeless people with disabilities. Matulef et al. (1995) and Fosburg et al. (1997) 

provide some suggestive, if partial, findings related to length of stay of residents of permanent 

housing and S+C programs respectively and the immediate destinations of those residents who 

left during the term of the studies and their reasons for leaving. Matulef et al. (1995) concludes 

that 69 percent of Permanent Housing residents remained in the housing for at least one year; in 

contrast, 31 percent of Permanent Housing residents had left their residential situation in the 12 

months before the research questionnaire was administered. About half of those who left entered 

stable subsidized or unsubsidized housing; a sixth went to live either stably or unstably with 

friends or family; and a third entered non-housing situations, such as hospitals, emergency 

shelters or the streets. Overall, they found little variation in the destinations of leavers based on 

whether they had left the housing voluntarily or involuntarily, with the exception that those 

residents affected by serious mental illness who left voluntarily were much more likely to be in 

permanent housing or with friends or family than those who had been dismissed. The authors 

indicated that “the length of time that these residents (residents who left their Permanent Housing 

project) remained in their new housing and the availability of supportive services to them there is 

unknown.” 

Based on early and fragmentary program information, Fosburg et al. (1997) concluded that most of 

the significant improvements in participant outcomes occurred early (that is, between the time of 

initial assessment and the three-month follow-up interview) in the residency of participants of S+C 

projects. While most of the improvements persisted from the three-month and the nine-month 

interviews, a few areas of improvement and a few declines were observed. The attrition rate of all 

S+C projects was 32 percent per year, that is, nearly one-third of the residents at the beginning of the 

year leave before the year is out. Over half of the residents in each of the first two years had 

remained in the S+C setting for at least six months. The most attrition occurred early at a resident’s 

stay, that is, within the first six months. An equal proportion of the known reasons for departure 

were voluntary and involuntary. 

In addition to data from the APR and the two formal evaluations just cited, several studies have been 

published in peer-reviewed journals, which document the departure rate (rate of leaving) and length of 

stay of program participants in permanent housing. Permanent housing programs included in these 

studies were not restricted to the three HUD-funded permanent housing programs. But regardless of 

funding sources, all programs shared the common feature of combining permanent community-based 

housing and with ongoing supportive services to a disabled homeless population. Based on a 

sample of 1,649 permanent housing residents who were also homeless veterans, Kasprow et al. 

(2000) found a departure rate of 16 percent within one year of entering into the program. In 

another study of 655 homeless veterans with psychiatric or substance abuse problems, Mares, 

Kasprow and Rosenheck (2004) found the average housing tenure to be 15 months over a three 

year period after entry. A highly publicized study of 139 New York City program participants in a 

SHP-supported Housing First setting by Tsemberis (1999), in contrast, found a consistently high 

program retention rate of 84 percent after a 30-month period. It needs to be said, though, that, in 

4 
contrast to the APR percentages cited above, Tsemberis is able to count as retentions people who 

left on an occasional basis (e.g., to a state hospital or drug treatment facility) and returned to the 

Housing first site. The APR as currently structured cannot capture such episodic circumstances. 

As a result, it is currently impossible to compare the Housing First retention rates with those of 

other permanent housing responses to the same population. 

Characteristics Associated with Housing Instability and Leaving Permanent Housing 

Prior research has provided limited and inconclusive information about participant and program 

characteristics associated with housing instability and departure from permanent housing. 

Kasprow et al. (2000) found female participants and participants whose case manager had made 

an effort to procure Supplemental Security Income (SSI) benefits more likely to be stably housed 

after one year in permanent housing than their counterparts. Four studies on the residential 

careers of the homeless mentally ill population found substance abuse to be a predictor of poor 

housing outcomes defined as housing instability or poor housing quality/conditions (Dickey et al. 

(1996); Goldfinger et al. (1999); Hurlburt, Hough, and Wood (1996); Tsemberis and Eisenberg 

(2000)). While Tsemberis and Eisenberg (2000) found a diagnosis of mood disorder to be 

associated with housing retention, Hurlburt, Hough, and Wood (1996) found no effect of 

psychiatric diagnosis on housing stability. 

A related study of the housing and neighborhood characteristics of Section 8 housing units 

developed under the Robert Wood Johnson Foundation Program on Chronic Mental Illness 

(RWJ) (Harkness, Newman, and Salkever 2004) found the following environmental predictors of 

residential stability: (1) Newer and properly maintained buildings; (2) buildings with fewer 

units; (3) buildings with greater proportion of non-mentally ill persons; (4) neighborhoods with a 

higher proportion of renters; and (5) non-residential neighborhoods. Mares, Kasprow, and 

Rosenheck (2004), found that housing tenure, mutually agreed discharge (versus prematurely 

discharge), independence of housing and employment status more strongly predicted client 

outcomes than participant characteristics. 

Research Questions 

As reported above, housing tenure is neither long-term nor permanent for a significant portion of 

program participants of permanent supportive housing. But while the incidence of leaving 

permanent housing and the limited nature of housing tenure is well documented, little is known 

about the circumstances surrounding departure from permanent housing and the residential 

history of participants once they have left permanent housing. This study, we trust, will in some 

ways rectify that situation. 

This project has identified three topical areas and their associated research questions critical to 

the HUD in its administration of permanent housing programs for homeless people with 

disabilities: 

5 
•	 Characteristics of permanent supportive housing. What are the distinctive 

characteristics of permanent supportive housing programs? Is permanent supportive 

housing a form of housing that permits long-term residency but in practice is used as 

transitional housing? 

•	 Circumstances of leaving and the post-permanent housing careers of leavers. What 

happens to the formerly homeless people with disabilities who leave permanent housing 

and why do they leave? What do leavers’ post-permanent housing residential careers look 

like over time? Do people who leave permanent housing voluntarily have different 

residential careers after permanent housing than those who leave involuntarily? 

•	 Factors associated with leaving permanent housing and post-permanent careers. What 

factors, including the degree and nature of disability and the length of time without housing 

at the time of program entry, affect the prospect of leaving or staying in permanent 

housing? What factors, including the degree and nature of disability and the length of time 

without housing at the time of program entry, affect where leavers go upon departure from 

permanent housing? 

Study Site Selection 

The study site for this project is the City of Philadelphia, Pennsylvania. The study population is 

comprised of adults with serious mental illness who are participants of HUD-assisted and cityassisted permanent housing in the City1

. 

Philadelphia was selected as the study site for several reasons. First, the City, through its Office 

of Mental Health (OMH), has a single-point of entry for gate-keeping referral and placement for 

all HUD-assisted and city-assisted permanent housing programs for adults with serious mental 

illness, the majority of whom reported a prior history of homelessness. The gate-keeping 

vehicle, the Access to Alternative Services Unit (AAS), conducts assessment and placement of 

applicants and monitors discharge of permanent housing leavers. This system permits 

researchers to track persons leaving permanent housing. Second, the City can claim one of the 

earliest and most comprehensive operational homeless management information systems (HMIS) 

in the nation. Since 1990, the Philadelphia Office of Emergency Shelter and Services (OESS), a 

public agency charged with managing emergency services for homeless people, has maintained 

a centralized mainframe database that collects and stores data on all people (including single 

adults and families) using OESS-funded shelter services. It is estimated that the OESS-funded 

services (and, therefore, the HMIS) cover about 85% of all shelter beds in the City. Third, 

access to a longitudinal integrated database developed by the University of Pennsylvania Center 

for Mental Health Policy and Services Research (CMHPSR) on publicly funded services across 

different service systems including homeless services, behavioral health treatment services and 

1

 The eligibility criteria for permanent supportive housing in Philadelphia are as follows: (1) a primary diagnosis of 

major mental illness, including schizophrenia or major affective disorder, as ascertained by a psychiatric evaluation; 

(2) current residence in Philadelphia for at least six months, exclusive of any institutionalization; and (3) at least 18 

years of age. In addition, depending on the type of housing subsidy available, psychiatric consumers have to 

demonstrate a prior history of homelessness or be currently homeless. 

6 
all residential services funded and managed by the City Behavioral Health System for persons 

with serious mental illness, enables the research team to track service use during different phases 

of permanent housing participants’ residential careers—prior to entry to permanent housing, 

during permanent housing, and post-permanent housing exit (for leavers). Participant and 

service characteristics that are associated with leaving permanent housing and post-permanent 

housing residential careers can thus be identified. In addition to the longitudinal integrated 

database, information collected from a National Institute of Mental Health (NIMH)-funded study 

conducted by faculty members at CMHPSR was merged with the integrated database to examine 

the impact of housing program characteristics on staying in and leaving permanent housing2

. 

The availability of a rich array of data notwithstanding, the findings from a single site (that is, 

Philadelphia) may not be generalizable to the universe of permanent housing nationwide in a 

strict statistical sense. Nevertheless, the diversity of permanent housing programs in operation in 

Philadelphia ensures that Philadelphia’s experience reflects that of many of its other urban 

counterparts. Moreover, within the resources available, this project was able to maximize the 

likelihood of tracking a sample of clients of sufficient size to permit statistically significant 

findings. Arriving at a sample of permanent housing program participants, especially of leavers, 

requires the cooperation of the City, housing and case management providers and sample 

participants. Conducting the study in a single site facilitated such cooperation, thereby 

increasing the validity of the study findings by reducing the rate of refusal and sample attrition. 

The Rest of This Report 

Chapter 2 describes the methods employed in this project. Chapter 3 provides background on the 

Philadelphia behavioral health system and summarizes characteristics of permanent housing 

programs in Philadelphia, the incidence and timing of discharges from permanent housing. 

Chapter 4 focuses on the circumstances of leaving and the post-permanent careers of leavers by 

looking specifically at destinations to which leavers departed from permanent housing, the 

reasons and scenarios of leaving and the post-permanent housing residential careers of leavers, 

including a comparison between those who left voluntarily and involuntarily. Chapter 5 

examines the factors associated with leaving permanent housing and post-permanent housing 

careers. Chapter 6 offers a summary and discusses the implications of our findings. 

2

 The title of the study - “Community Integration of SMIs in Supportive Housing”. The Principal Investigator (P.I.) 

is Y.L. Irene Wong, Ph.D., and co-P.I. is Phyllis Solomon. The study is supported by a three-year Research 

Enhancement Grant funded by the National Institute of Mental Health. 

7 
8
 
CHAPTER 2: METHODS 

Introduction 

This study used two tracking methods to collect data from leavers and stayers of permanent 

housing: (1) retrospective tracking using an integrated longitudinal administrative database of 

943 individuals who had ever stayed in permanent supportive housing for persons with serious 

mental illness within the City of Philadelphia between January 1, 2001 and July 15, 2004 and (2) 

prospective tracking of 100 individuals who left permanent housing from February, 2003 to 

December, 2004; and (3) a comparison sample of 100 individuals who were current permanent 

housing residents as of January, 2005. We designed selection of both the retrospective and 

prospective tracking samples to maximize use of the integrated longitudinal database uniquely 

available in Philadelphia and to facilitate a workable strategy to track permanent housing leavers 

over an 18-month period so as to secure reliable information on post-permanent housing 

residential careers. Specifically, the use of the retrospective sample provides statistical power 

for a quantitative analysis of participant, service, and program characteristics that predict leaving 

and staying in permanent housing. Collection of interview data from participants and providers 

in the prospective sample provides quantitative as well as qualitative information on the 

circumstances surrounding departure from permanent housing and the post-permanent housing 

residential careers of permanent housing leavers. The development of the two data collection 

methods is discussed below. 

Retrospective Tracking of Leavers and Stayers of Permanent Housing through the 

Integrated Longitudinal Administrative Database 

Selection of the Retrospective Tracking Sample 

All 943 persons who participated in Philadelphia’s permanent housing programs for people with 

serious mental illness between January 1, 2001 and July 15, 2004 were selected into the 

retrospective sample. Among the 943 permanent housing residents, leavers were designated as 

those who left permanent housing anytime between January 1, 2001 and July 15, 2004. Stayers 

are designated as those who were not discharged from the permanent housing program during the 

same time period. Altogether, 385 are classified as leavers and 558 as stayers. The numbers of 

leavers for the calendar years 2001, 2002, and 2003 are, respectively, 109, 123, and 107. The 

number of leavers who left permanent housing between January 1, 2004 and July 15, 2004 was 

46. The sample size of 943 participants is large enough to provide adequate statistical power for 

identifying participant, service, and program characteristics that predict staying in or leaving 

permanent housing. 

To estimate the incidence and timing of leaving for residents who were entering permanent 

housing, a sub-sample of three cohorts entering permanent housing in 2001, 2002, and 2003 was 

selected from the total 943 residents. The numbers of permanent housing residents in the three 

cohorts are as follows: 152 in 2001, 134 in 2002, and 152 in 2003. Analysis of these three 

9 
cohorts gives a more accurate picture of the incidence and timing of leaving than using the entire 

retrospective sample of 943 residents. Including leavers who started their permanent housing 

career before 2001 but left after 2001 effectively underestimates the incidence of leaving while 

overestimating the length of stay in permanent housing among leavers. 

The Integrated Longitudinal Administrative Database 

This project employed an integrated longitudinal administrative database on publicly funded 

services to consumers in Philadelphia. The database was constructed using information from 

administrative data files from multiple service systems. These administrative data files were 

obtained through contractual arrangements between the University of Pennsylvania Health 

System’s Center for Mental Health Policy and Services Research (CMHPSR) and the City of 

Philadelphia. This agreement, which permits use of these data sets for City-approved research 

projects, is subject to review and approval by City officials. This study received such approval. 

In addition, the agreement requires the approvals of both the University of Pennsylvania and the 

City Institutional Review Boards, which were obtained. Identified data are de-identified for all 

analysis purposes, and all staff that use these data sets sign confidentiality agreements. Further 

information about the data security issues is available from the CMHPSR. Both foundations and 

the federal government ((the National Institutes of Mental Health (NIMH)) have supported the 

development of the integrated longitudinal database over the last 11 years and have allowed 

researchers at CMHPSR to arrive at sophisticated computer algorithms that match individuals 

and services, using different identifiers across systems and over time. Community residential 

programs, City-funded behavioral health services, public shelters, and Medicaid-funded mental 

health services are in the database used for this study. The following is a description of the three 

administrative data sets: 3 

Client Reporting System (CRS)—The Office of Mental Health (OMH) is the mental 

health authority responsible for all publicly funded behavioral health programs in Philadelphia. 

All agencies record individual client level data on client characteristics at admission and 

discharge and client services by date, type, provider and unit of service. The residential 

placement file includes data on client identifiers, date of residential placement referral (including 

all permanent housing placements for formerly homeless people with serious mental illness), 

sources of referral, placement decisions, date of admission to and discharge from residential 

services, and information on the residential services such as type of programs, location and 

provider agencies. 

Office of Emergency Shelter and Services Data (OESS)—The Philadelphia Office of 

Emergency Shelter and Services is the central agency for managing emergency services for 

3

 In addition to these data sets, the research team attempted to acquire an automated data set from the jails in 

Philadelphia. Although data is available for 2003, prior years’ data was adjudged unreliable and could not be used 

for this study. In previous work in New York, investigators found relatively few persons who were seriously 

mentally ill and homeless in the jail information systems. The research team also attempted to match the study 

cohort to the street outreach data which Philadelphia collects on homeless persons contacted by the street outreach 

teams. No matches were found with any of the leavers or stayers in the longitudinal data set in the street outreach 

data files. Although this finding is encouraging, it may not be very meaningful because the street outreach data has 

extremely limited identifiers and, therefore, cannot be used to draw conclusions about the number of leavers or 

stayers who may be “on the streets.” 

10 
homeless people. Since 1990, OESS has maintained a centralized mainframe database that 

collects data on persons using OESS-funded shelter services (the database does not include 

shelters and other residential facilities for homeless people administered by the mental health 

system). According to best estimates, this covers approximately 85 percent of the citywide 

shelter beds. Information available in this database includes identifiers (name, date of birth, 

Social Security number, and Medicaid number), initial intake date, demographics, marital and 

family status, reasons for homelessness, last two addresses, characteristics of prior housing 

arrangement, emergency contact persons, names and ages of accompanying children, medical 

problems, and stay history information for all shelter episodes. 

The Management Information System of Community Behavioral Health (CBH)—The 

City of Philadelphia controls all Medicaid (Medical Assistance) revenues for behavioral 

healthcare and provides Medical Assistance (MA) benefits to recipients. CBH also coordinates 

services provided through the City’s public mental health and substance treatment services 

systems. This system provides micro-level client data on mental health, drug and alcohol abuse 

treatment, inpatient visits, all clinic and community support services, and pharmacy/prescriptions 

provided to Medical Assistance-eligible Pennsylvania residents. 

For purposes of this study, we used five common identifiers to merge the administrative datasets: 

First and last names; sex; date of birth; and social security number. Segments of the first four 

identifiers were combined to create a unique identifier that was used to match cases across 

databases. Also, social security numbers were used to provide additional matches when the other 

identifiers were missing or contained erroneous data. All leavers and stayers of permanent 

housing in the retrospective sample were identified through the CRS residential placement file. 

In essence, the team was able to track the program participants leaving and staying in permanent 

housing across all of these data sets. We were able to determine the services used by each 

individual participant, the sequence of services used, and the rate of service utilization for the 

retrospective sample. 

Data Quality Issues of Longitudinal Integrated Database 

Based on extensive experience with the administrative data sets, the CMHPSR is well aware of 

potential problems resulting from the use of secondary data sources collected for routine 

administrative use. Thus, drawing on the technical expertise from CMHPSR, the study was able 

to use a data management protocol that includes reliability and validity auditing of data elements 

and the maintenance of data standards. Algorithms linking individual participants across 

databases have been refined and tested extensively to ensure that linked information is for the 

same person. 

Data Analysis 

We analyzed integrated longitudinal data concerning the pre-permanent housing, duringpermanent housing and post-permanent housing residential and service use careers of leavers, 

including the incidence and length of time spent in public shelter, inpatient psychiatric units, 

various outpatient and community rehabilitation services, and other publicly-funded residential 

11 
placements. In addition, we made comparisons between leavers and stayers to determine if there 

are significant differences between the two groups in socio-demographic and psychiatric 

diagnostic characteristics, residential and service use careers pre-permanent housing and duringpermanent housing. 

Following this descriptive analysis, we estimated the effects of individual and service predictors 

on staying in and leaving permanent housing using multivariate logistic regression. 

Characteristics included in the regression model were selected either as statistical control (for 

example, basic socio-demographics) or because of the statistical significance in the descriptive 

analyses. Socio-demographic and control variables that were included in the multivariate 

analysis are gender, age, race/ethnicity, and the time in permanent housing. Pre-permanent 

housing service use characteristics include public shelter stay and use of community residential 

services. During-permanent housing service use characteristics include inpatient and emergency 

services use and use of a number of outpatient services. 

Prospective Tracking of Leavers and Stayers of Permanent Housing through Interviews 

Initial Contact with Permanent Housing Programs 

In February 2003, a letter from the research team containing background information about the 

study was sent to all participating permanent housing programs. The letter offered detail about 

how the permanent housing program staff would be asked to participate. Enclosed was another 

letter from the City Behavioral Health senior managers requesting permanent housing program 

cooperation. A meeting with the research team and each permanent housing provider to answer 

questions and encourage participation followed. 

Recruitment of the Leaver Sample 

Leaver recruitment efforts targeted two categories of leavers: (1) actual permanent housing 

leavers; and (2) prospective leavers. Targeted actual leavers comprised all those who departed 

from permanent housing programs in Philadelphia from February 2003 to December 2004. All 

actual leavers were identified by an updated cumulative permanent housing discharge list 

received biweekly from OMH staff. Agency case managers sent letters to those discharged from 

permanent housing to inform them of the interview study. Those interested in study participation 

were instructed to contact their residential support staff or, if they preferred, research staff 

directly. A research staff member followed up with interested leavers. Research staff described 

what the study was about, what participation would entail, and how much study participants 

would be paid. For those who had not contacted residential support staff to opt explicitly out of 

the study, residential staff would, where possible, follow up to assess interest. 

 Recruitment of prospective leavers primarily consisted of a three-pronged strategy: (1) direct 

mailing of study materials to “scattered site” permanent housing residents; (2) permanent 

housing case managers or other staff members would distribute materials describing the study at 

12 
venues/meetings with potential prospective leavers. If and when they became a leaver, they 

could then call research staff directly or indirectly through their permanent housing staff 

member; and (3) research staff called case managers and program directors biweekly to inquire 

about anticipated discharges and contact information for leavers living outside of the permanent 

housing program. Program cooperation varied from program to program. Additionally, once the 

study began, study participants occasionally provided contact information for friends or 

acquaintances (currently in permanent housing or anticipated discharges) who had indicated an 

interest in participating. 

For those who consented to take part, research staff scheduled a time and place to complete the 

consent procedure and the interview. During the baseline interview, researchers asked study 

participants to provide contact information for five close contacts who might know their 

whereabouts and then asked the study participant to sign a participant tracking consent form. 

Study participants were told they had the right to refuse to provide the tracking information. The 

study participants were also presented with a consent form permitting the research team to 

contact them between sessions should they be admitted to a hospital, homeless shelter, jail or 

prison. Study participants were again alerted that they had the right to refuse to be contacted in 

these locations and that refusal to be contacted would not jeopardize their status as study 

participants. 

Attempts were made to contact each study participant monthly, either in-person or by telephone, 

to track his/her residential history and the reason for staying or leaving his/her most recent 

residence after moving out of permanent housing. Each interview, including the baseline and 

follow-up, took about 20 minutes. Leaver participants were compensated with $20 cash for the 

first session and $10 for each monthly follow-up session. During each session, the research staff 

reminded participants to call the study’s toll-free number should they move or change their 

phone numbers. They also attempted to coordinate the date, time and location of the subsequent 

month’s interview. When interviews were conducted by phone, participants were asked to 

provide a mailing address to receive their compensation. 

Information Collected at Baseline and Follow-Up Conversations with Permanent Housing 

Leavers 

Information collected during the baseline conversations included: (1) the circumstances under 

which participants left permanent housing; (2) expectations of and experiences while in the 

permanent housing; (3) whether participants considered their departures voluntary or 

involuntary; (4) homelessness history; (5) type of residence to which they moved after leaving 

permanent housing; (6) living arrangements in their current residence (that is, living alone or 

living with family and friends); (7) whether they paid rent, mortgage or contributed to household 

expenses in their current residence, and, if so, how much; (8) current mental health support and 

services; (9) current income sources and employment status; (10) activities in which they 

currently engaged; (11) subjective assessment of their quality of life; and (12) basic 

demographics. 

13 
The monthly follow-up conversation guide included the following topics: (1) the residential 

history and employment history of the participants’ subsequent to the last discussion; (2) the 

participants’ subjective assessment of current quality of life; (3) current mental health support 

and services; (4) activities engaged in; (5) personal income sources; (6) feelings about their 

current residence; and (7) if they have considered returning to permanent housing. 

Tracking Strategy Used to Increase Retention of Permanent Housing Leavers 

Existing literature indicates homeless or formerly homeless persons can be very difficult to track 

(for example, Trials, Tribulations and Occasional Jubilations While Conducting Research on 

Homelessness by Toro, Wayne State Dept of Psychology, 2002). To maximize participant 

retention, research staff undertook a number of intensive strategies to locate permanent housing 

leavers who could not be contacted within two months after the previous interview. These 

strategies included checking names/identifiers against the OESS database to locate participants 

who used public shelter, using information from participants’ relatives and friends, and locating 

participants who were institutionalized through contacts with jails and other local service 

agencies. Successful participant tracking required a proactive approach. The method employed 

adapted a method developed for a major clinical trial involving homeless mentally ill men in 

New York City (Susser et al. 1997), and used subsequently in two other studies of inner-city 

homeless people (Susser et al. 1995). The essential features of this approach included 

maintaining continuity of research personnel, frequent contacts with study participants, 

knowledge of a person’s life style, triage to target residentially unstable study participants for 

more intensive follow-up, incentives, and adequate training and supervision of research staff. 

The study design included monthly contact of participants. The intent of this design was to 

increase retention and interview completion rates among participants. Those difficulties were 

experienced primarily because current contact information was unavailable and/or the network of 

family and friends lost contact with the participant. The research team also fostered its contacts 

with field case managers and outreach staff within the community who could potentially alert us 

to status and location of “lost” leavers. 

Even with a carefully crafted consent procedure and rigorous tracking strategies in place, we 

encountered potential participants who refused to participate in the study (as participation was 

voluntary) and were unable to maintain contact with some participants who initially agreed to 

participate. The research team anticipated that refusal and attrition would be more serious 

among leavers who departed from permanent housing involuntarily and/or because of 

unfavorable circumstances. We “tracked” those who refused and participants lost between 

interviews using the integrated longitudinal database and examined whether permanent housing 

leavers who refused to participate or who were lost in the follow-up were significantly different 

from permanent housing leavers who completed the interview study and found no statistical 

demographic differences between the groups. 

Recruitment of the Stayer Sample 

In August 2004, we began recruiting and interviewing permanent housing stayers. We sent 

letters to permanent housing agency administrators and then followed up with phone calls to 

ensure receipt of the mailings and verify provider willingness to cooperate. Next the names and 

14 
personal identifier codes of potential participants for the stayer sample were provided to 

permanent housing staff. 

Research staff derived the stayer list by matching interviewed leavers with stayers using the 

demographics in the integrated longitudinal administrative database. Leavers and stayers were 

matched by gender, race, birth year, and date of admission into permanent housing. Staff then 

computed a similarity score between each interviewed leaver and all unmatched stayers. Stayers 

were targeted for recruitment into the study if they matched the similarity score of a participating 

leaver.4

 Two matches were generated for each leaver to ensure there was a back-up matched 

stayer. Residential support staff then attempted to contact the primary matched stayer to obtain 

consent for contact. Support staff confirmed his/her status as a stayer, informed the stayer about 

the study and offered each the opportunity to participate. If the primary match proved unwilling 

or unable to participate, they then pursued the secondary match. 

Permanent housing stayers who consented to participate in the study were contacted by the 

research team or, at times, initiated contact with the research team themselves. During initial 

contact, a time and location to complete the consent procedure and conduct the one-time 

interview was scheduled. Staff conducted only baseline interviews with stayers. Each interview 

took about 20 minutes. Participants were given $20 upon interview completion. 

Information Collected at Interviews with Permanent Housing Stayers 

Information collected at interviews with permanent housing stayers covered the following topics: 

(1) the situation under which each participant entered permanent housing; (2) personal homeless 

history; (3) current living situation/arrangement; (4) current mental health support and services; 

(5) activities in which he/she is currently engaged; (6) current income sources and employment 

status; (7) current rent payment; (8) subjective assessment of one’s quality of life; and (9) client 

preference for staying in permanent housing or moving to another living arrangement. 

Challenges the Project Faced in Participant Recruitment and Tracking 

The recruitment period lasted approximately 24 months (Leavers - February, 2003 to December, 

2004; Stayers – September, 2004 to January, 2005). Overall, the goal of the recruitment effort 

was to maximize participation and retention in the study. We experienced lower than expected 

participation and retention rates among leavers. This was a function of a number of recruiting 

challenges, including: (1) as it worked out in practice, participants needed to be recruited via an 

intermediary third party, that is, permanent housing residential support staff, since they were the 

source of access to residents; (2) reluctance of some residential support staff members to inform 

their clients about the study; (3) unwillingness of some potential participants to participate 

because they were unwilling to share information about themselves; (4) the mental condition of 

4

 Stayers targeted for recruitment in the project were those that have a “4” (4 of 4 variables matched) or “3” (3 of 4 

variables matched) in the similarity score. The stayer with the highest similarity score was matched to the leaver 

being evaluated. 

15 
some potential participants at some points compromised their ability to participate meaningfully 

in some scheduled discussions, thereby demanding rescheduling; and (5) contact information 

was sometime outdated or unavailable. Additionally, there were obstacles which affected both 

the recruitment and retention of leavers, such as: (1) the initial belief among some participants 

that the interviewer had input or influence on their housing situation. Some simply did not want 

to continue when it was made clear to them that the interviewer would have no influence on their 

housing; (2) “involuntary” discharged leavers were most difficult to contact or track given they 

were less likely to have a stable post-permanent housing residence; and (3) additionally, some 

involuntary leavers left their permanent housing residence on very unfavorable terms and 

unavoidably associated the research team with their negative relationship with the permanent 

housing program. 

Participation and Refusal Rates of Leavers and Stayers (Baselines) 

Among the 259 individuals identified as leavers in Philadelphia between February 2003 and 

December 2004, 15 (6%) died prior to contact from the research team. Generally, in 

Philadelphia, permanent housing residents who have terminal health conditions are discharged to 

a hospital/hospice. Most of these patients left permanent housing because of these significant 

health conditions and were admitted to another facility for care. We have no evidence to 

suggest that departure from permanent housing settings precipitated these deaths. 

An additional seven individuals (3% of 259) were eventually confirmed not to be leavers but 

permanent housing residents who had been formally transferred to another program. Five 

permanent housing leavers were later identified to have experienced two discharges during the 

period of the study. In other words, they left permanent housing, were readmitted to the program 

and subsequently left again. In the longitudinal database study, these clients are included but for 

the interview study the second leaving was included for tracking purposes. Thus, among the 237 

leavers who were eligible and potentially available for the study, 42 percent agreed to participate 

and were interviewed, 36 percent declined to participate upon contact, and we were simply 

unable to contact 22 percent. 

The permanent housing leaver population is difficult to track even with an administrative 

database, in part because: (1) many leavers, whether voluntary or involuntary, are reluctant to 

share personal information. Voluntary leavers may want to disassociate themselves from their 

homeless past, and involuntary leavers are frequently not interested in communicating with their 

previous permanent housing provider or case manager, particularly if they believe their discharge 

was unfair; (2) permanent housing providers do not always maintain contact and/or do not have 

current contact information for their leavers, and especially so if their departure was negative; 

and, (3) there is a lag time between changes in the residence, services or disposition of leavers 

and when they are recorded in the administrative databases, a circumstance which limits the 

effectiveness of the administrative database for “real-time” tracking. 

Among the 213 stayers selected into the sample, 100 (47%) consented to be interviewed and 113 

(53%) declined to participate. As discussed above, follow-up interviews were difficult; out of a 

16 
possible 1,011 monthly opportunities, 532 (53%) monthly follow-up discussions were 

conducted. Overall, 31% (30) of study participants averaged one follow-up interview (FUP) per 

month; 39% (37) averaged one FUP every two months; 16% (15) averaged one FUP every four 

months; 4 % (4) averaged one FUP every six months; 6% (6) averaged one FUP every +six 

months; and 4% (4) never completed a FUP. 

Consumer Background Form Filled by Residential Support Staff 

Aside from the leaver and stayer interviews, the project obtained information about study 

participants’ characteristics and circumstances of leaving (for leavers only) from residential 

support staff that filled out a consumer background form for each participant. Either a 

permanent housing case manager who had been assigned to the consumer or his/her immediate 

supervisor would fill out the background form. In general, they are social workers or counselors 

with graduate degrees and, of all provider staff, have the most direct relationship with the 

consumers. The information collected included: (1) the circumstances under which participants 

left permanent housing (for permanent housing leavers only); (2) whether the staff person 

considered a participant’s discharge voluntary or involuntary (for permanent housing leavers 

only); (3) the perceived level of functioning and behavioral characteristics of participants (for 

permanent housing leavers and stayers); (4) type and intensity of services the participants have 

received while in permanent housing (for permanent housing leavers and stayers); and (5) 

psychiatric diagnoses as reported by providers (for permanent housing leavers and stayers). 

17 
18
 
CHAPTER 3: CHARACTERISTICS OF PERMANENT HOUSING PROGRAMS FOR 

PERSONS WITH SERIOUS MENTAL ILLNESS IN PHILADELPHIA, 

PENNSYLVANIA 

Introduction 

In the first chapter, we pointed out that having a single point of entry for all HUD-assisted and 

City-assisted permanent housing programs for adults with serious mental illness was one of the 

key reasons for the selection of Philadelphia, Pennsylvania, as the study site of this project. In 

Philadelphia, the Office of Mental Health (OMH) manages access to HUD- and City-assisted 

permanent housing for persons with serious mental illness. The Access to Alternative Services 

(AAS), an administrative unit within the OMH, acts as a centralized gatekeeper, conducting 

assessment and placement of applicants, as well as monitoring discharge of permanent housing 

leavers. Other persons with mental illness may have access to HUD-assisted permanent housing 

through other service systems such as the AIDS Activities Coordinating Office (AACO) or the 

Office of Emergency and Shelter Services (OESS) because their primary disabling condition 

may be a physical disability, HIV/AIDS or chemical dependency and their mental illness a 

secondary co-morbid condition. However, individuals with the most disabling and chronic forms 

of mental illness requiring long-term psychiatric supports have access to permanent housing 

programs primarily through the public mental health system. 

This chapter gives an overview of the distinctive characteristics of permanent housing programs 

within the mental health system in Philadelphia. The chapter begins by giving a brief 

background of publicly-funded community-based mental health services in the city and 

permanent housing programs for persons with serious mental illness. This is followed by a 

description of the key characteristics of permanent housing programs using data collected for a 

federally-funded study on community integration of persons with serious mental illness in 

permanent housing. Lastly, we examine the incidence and timing of departures from permanent 

housing using the integrated longitudinal tracking data collected as part of the current project. 

Our summary notes that Philadelphia has been responsive to the growing needs of the homeless 

community by utilizing HUD and local funding to expand its permanent housing programs. The 

programs created/expanded have different configurations of housing and service components to 

address the unique needs of the homeless mentally ill population. The “support” element of the 

programs is considered essential to promoting the independence of their residents. As part of this 

overall program development, the City’s behavioral health system created a housing 

development corporation (1260 Housing Development Corporation) specifically designed to 

increase the pool of housing for persons with psychiatric disabilities that has successfully added 

a significant number of permanent housing units for mentally ill homeless persons. The housing 

has been developed in diverse neighborhoods that tend to have lower household incomes, higher 

incidences of crime, and higher proportions of rental units than does the city at large. However, 

the 113 neighborhoods where permanent housing residents lived are not any more distressed than 

the total of 1,816 neighborhoods in the city. Although permanent housing has been designed to 

fulfill the long-term housing needs of formerly homeless persons, about three of ten leave during 

the first 18 months of residence and half do by 30 months. It is this population of “leavers” that 

is the principal focus of this study. 

19 
Background of the Study Site: Mental Health Services and Permanent Housing 

Public Mental Health Services in Philadelphia 

The public mental health system in Philadelphia has evolved over the past four decades in 

response to the emerging needs of persons with severe and persistent mental illness. Two 

important and inter-related forces have shaped community mental health services, as well as the 

permanent housing programs for persons with serious mental illness (SMI): (1) the national 

trend of deinstitutionalization, as evidenced by the closure of public psychiatric hospitals and the 

growth of community-based support services; and (2) the emergence and persistence of 

homelessness as a major social problem. 

The roots of deinstitutionalization in the U.S. can be traced to the 1950s, in the wake of powerful 

documentary evidence of the abuse and neglect of people with mental handicaps (that is, 

developmental disabilities, SMI & dementia) in state institutions. The deinstitutionalization 

movement encouraged policies shifting people with mental handicaps from confinement in 

hospital settings towards provision of services at the community level. The psychiatric patient 

populations in public mental hospitals in the U.S. declined nearly eightfold from an estimated 

560,000 patients in 1955 to about 72,000 in 1994 (Manderscheid and Henderson 1996). In 

Philadelphia, as in much of the U.S., there have been two distinct periods of 

deinstitutionalization; the first, largely in the late 1970’s and early 1980’s, was characterized by 

an absence of planning for the patients discharged from the hospitals and a lack of adequate 

community resources to care for them post-discharge. This crisis in public response eventually 

manifested itself in public perception that homelessness was the direct result of mental health 

policy. The deeper roots lay largely in the antiquated financing structures of mental health 

services where no funding followed the clients into the community and an almost complete 

clinical and ideological disjuncture between the federally funded and managed community 

mental health centers and the state operated and funded state psychiatric hospitals (Hadley 1996; 

Stiles, Culhane, and Hadley 1996). Neither state mental health authorities nor community 

programs were ready for this shift, and, in Philadelphia, like much of the rest of the U.S., it took 

many years of public policy struggle and service system realignment to develop a reasonable 

community system. 

The second generation of deinstitutionalization is best exemplified by the closure of Philadelphia 

State Hospital (PSH), the only public psychiatric hospital in the city, in June 1990. The closure 

of PSH signaled a new stage in the deinstitutionalization movement. Whereas previous hospital 

closures led to the consolidation of psychiatric patients among state hospitals, all patients of PSH 

were targeted for discharge into the community and all future state hospital admissions in 

Philadelphia were to be diverted into community-based services. Most importantly, the State of 

Pennsylvania transferred 100% of the funding that had been used to support PSH to the City’s 

Behavioral Health System (BHS) to plan and create new and appropriate services for both the 

discharges and the diversion groups. Ninety-six percent of all eligible PSH patients were 

successfully placed into a variety of community living arrangements, including supported 

apartments, group homes, scattered apartments, and structured long-term residences. Several 

20 
studies of this placement process have been completed and have found most patients to be living 

in the community and most very satisfied with their arrangements. A study currently underway 

is examining the long-term outcomes for this cohort, and preliminary results indicate the vast 

majority are still living in the community. A diversion system was also established to provide 

services for ex-PSH patients, as well as for prospective psychiatric patients who meet the 

eligibility criteria of PSH patients (Rothbard, Richman, and Hadley 1997). The diversion service 

system can be characterized as a comprehensive service network with various components, 

including case management, housing, mental health treatment, rehabilitation services, health and 

dental care, family, peer, and community support, and protection and advocacy. 

During that same period, homelessness emerged as a national social problem, and serious mental 

illness was persistently viewed by the American public as a major contributor to that epidemic. 

In response, the Philadelphia mental health system developed an array of community residential 

programs to meet its housing and service needs by leveraging funding from various levels of 

government and private foundations (Culhane, Averyt, and Hadley 1997). These residential 

programs include 320 progressive demand residence placements, low demand relatively 

unstructured group residential settings designed to encourage on-the-street homeless people to 

enter the care system; 145 mental health shelter placements targeted exclusively for the homeless 

mentally ill population; and approximately 2,000 other residential placements, ranging across 

locked facilities, group homes, and scattered-site apartments for mentally ill consumers who may 

or may not have experienced prior homelessness5. 

Permanent Housing Programs for Persons with Serious Mental Illness 

Permanent housing designated for persons with serious mental illness was introduced in 

Philadelphia in 1987 as a result of the City’s participation in the Robert Wood Johnson (RWJ) 

Program on Chronic Mental Illness, a program that focused on system integration of mental 

health services through the creation of local mental health authorities (Goldman 2000). As one 

of nine cities in the RWJ Program, Philadelphia was provided with an allotment of 125 Section 8 

housing vouchers from HUD to subsidize rents for individuals with serious mental illness so that 

they could afford housing. The 1260 Housing Development Corporation, a non-profit quasigovernment agency created under the auspices of the local mental health authorities, was 

established to develop and manage permanent, low-cost housing for persons with serious mental 

illness. 

HUD has played a major role in permanent housing programs in Philadelphia. From 1987 to 

2004, the Department awarded homeless providers and the city agencies of Philadelphia over 

$92 million in permanent supportive housing funding through the Supportive Housing Program 

(SHP) and Shelter Plus Care (S+C) program funds. It is important to note that the $92 million 

does not include other HUD programs that could support people who are both homeless and 

seriously mentally ill (for example, the Section 8 Single Room Occupancy, Emergency Shelter 

Grants, Section 202, Community Development Block Grants, Supportive Housing Program, and 

HOME supports). The major support HUD provides for permanent housing signals the 

5

 For a more extensive description of the array, see Appendix E of HUD report Strategies for Preventing 

Homelessness 

21 
importance of understanding permanent housing programs in Philadelphia and how they affect 

homeless people with serious mental illness. 

While the pivotal role played by the federal government in funding permanent housing for the 

homeless mentally ill population is unequivocal, state and local governments have also 

contributed significantly to the development of permanent housing programs in Philadelphia. 

Specifically, they have provided funding for permanent supportive housing at the closure of the 

Philadelphia state psychiatric hospital, funding targeted to the homeless mentally ill population 

as part of the City’s Sidewalk Ordinance (CSO), and funding for support services to match the 

housing subsidies provided by the federal government. 

Within the City’s mental health community residential system, permanent housing has grown 

tremendously from the original 125 Section 8 units in 1987 to a capacity in 2003 of 652 units in 

28 programs. The community residential system is a continuum of community living and service 

arrangements, including long-term structured residences, specialized residences for consumers 

with a co-occurring disorder, transitional group homes, supervised apartments, and supported 

independent living (SIL). Community residential support services constitute a critical 

component of the mental health system, comprising 51% of the OMH’s budget (personal 

communication with Lawrence Klugman, 2004). Within the residential continuum, permanent 

supportive housing (or SIL in the terminology of the OMH) has the least structured level of care 

and supervision and is designated for mental health clients capable of living independently with 

non-facility-based support. 

Permanent supportive housing differs from congregate community rehabilitation, transitional 

housing and group home settings by providing a long-term housing subsidy. Delivery of 

supportive services for most permanent housing residents is not facility-based in that most of the 

residential support teams are mobile teams and do not have offices in the buildings where 

consumers’ apartments are located.6 Residents of permanent housing pay up to 30% of their 

income in rent and are expected to stay in their housing as long as they fulfill their tenancy 

obligations and demonstrate an adequate level of functioning in the community. 

Applications for permanent housing targeted for persons with serious mental illness are 

processed through the AAS unit, which conducts assessments and placements for all applicants 

of community residential programs. Applicants for permanent housing with AAS must meet the 

following criteria: (1) a primary diagnosis of major mental illness, including schizophrenia or 

major affective disorder, as ascertained by a psychiatric evaluation; (2) current residence in 

Philadelphia for at least six months, exclusive of any institutionalization; and (3) at least 18 years 

of age. 

Homeless applicants who do not have a diagnosis of schizophrenia or major affective disorder 

may have access to other HUD-funded permanent housing units in the homeless service system 

(OESS) or in the HIV/AIDS service system (AACO), provided that they satisfy the eligibility 

criteria of permanent housing in these two systems, which include other forms of disability such 

as substance abuse problems, physical disabilities, and HIV/AIDS. Applicants who do not 

6

 Only a quarter (23.3%) of permanent housing residents had residential support teams located in the building where 

their residence was located. 

22 
satisfy the residency requirement are eligible once they reach the six-month tenure. Conditioned 

on the availability of housing subsidy and service support, potential permanent housing 

applicants of AAS who meet eligibility criteria are offered a housing subsidy and a choice of 

housing units. Permanent housing applicants who experienced prior homelessness are eligible 

for HUD-funded or city-funded housing subsidies targeted to the homeless mentally ill 

population and for other non-HUD-funded subsidies. Permanent housing applicants who have 

never experienced prior homelessness are eligible for non-homeless-designated subsidies only.7 

Although housing subsidies are an essential component of permanent housing in Philadelphia, 

the operation of permanent housing is not organized by sources of housing subsidy. Instead, 

permanent housing programs are organized by residential support teams, which are operated by 

agencies specializing in mental health services. These residential support teams are expected to 

provide the same level of support and services to both homeless and non-homeless clients. As 

our data in the following section show, permanent housing programs may serve their clients with 

both HUD-funded and non-HUD-funded subsidies. Unfortunately, administrative data available 

in the community residential system does not differentiate permanent housing residents by the 

sources of funding, so homeless persons cannot be separated out for analysis. 

There are some general requirements regarding income requirements for housing subsidies. In 

Philadelphia, the Residential Planning Team (RPT) has determined that clients must have an 

income of less than $1,000 per month to be accepted for placement into any Office of Behavioral 

Health (OBH)-subsidized placement. However, there are caveats to this requirement; 

specifically, if the client has either an extraordinary financial need (for example, pays for all of 

his own medications or pays child support, and so forth., thus reducing his disposable income) or 

an extraordinary clinical need (for example, has a relatively high number of inpatient stays/days), 

they could be eligible for housing subsidies. 

As regards financial eligibility, generally there is no differentiation between HUD-funded and 

non-funded programs. However, it is preferred that clients generally have an income equal to or 

greater than Supplemental Security Income (SSI) (that is, over $500 per month). The belief is 

that these clients would be less likely to fail than those who are only on public assistance (that is, 

about $205 per month). 

Characteristics of Permanent Housing Programs for Persons with Serious Mental Illness 

This section describes program characteristics central to the operation of permanent housing 

programs in Philadelphia. These characteristics include sources of housing subsidy, ownership 

of housing units, and neighborhood characteristics of housing units, provision of residential 

support services, and the housing preferences of permanent housing residents. 

The data presented here were collected as part of a National Institute of Mental Health (NIMH)-

funded study conducted by faculty members from the Center for Mental Health Policy and 

Services Research (CMHPSR). It should be noted that the NIMH-funded study is entirely 

7

 Note that it is very unusual for permanent housing applicants to directly receive a Section 8 voucher upon entry 

into the program. Permanent housing participants usually get access to Section 8 after they’re in the permanent 

housing program for a while, and then apply successfully for the voucher. 

23 
independent of this project, with data collected for a different purpose, that is, to examine 

community integration of persons with serious mental illness in supportive housing, and with a 

different methodology, a cross-sectional survey of current residents of permanent housing 

programs. Nonetheless, the target population of the NIMH-funded study, permanent housing 

residents in Philadelphia, overlaps with that of this project. 

Provider-level and consumer-level interview data are the primary sources of information, which 

are supplemented by administrative and census data. Interviews with 28 permanent housing 

support services providers were conducted between July 9, 2002 and May 12, 2003. Interviews 

with a cross-sectional sample of 252 permanent housing residents from all except two of the 28 

programs were conducted between July 19, 2002 and December 30, 2003. The 252 study 

participants were all residents in their apartments for six months or more. 

Definition of Permanent Housing Programs 

As previously mentioned, consistent with the definition used in the mental health system in 

Philadelphia, permanent housing programs were identified by residential support teams, which 

provide support services to individuals with serious mental illness who held HUD-funded or 

city-funded housing subsidies and stayed in permanent housing. As noted, in 2003 (the start date 

of this project), there were 28 permanent housing programs, or 28 residential support teams, 

providing services to 652 permanent housing residents.8 The occupancy rate of permanent 

housing at the time was 86 percent (that is, 558 residents). An enumeration of the capacity and 

occupancy of the 28 programs is contained in columns 1-2 of Table 3.1. 

8

 It should be emphasized again that the permanent housing programs are identical to residential support teams or 

programs, and that the mental health system defines programs by support team, not according to sources of subsidy. 

24 
TABLE 3.1: CAPACITY, OCCUPANCY, HOUSING SUBSIDY, & HOMELESSNESS 

Program Capacity Occupancy HUD SHP 

HUD 

S+C 

HUD 

Section 8 

Other 

HUD 

Local (OMH & 

others) 

No Federal 

Funding 

SHP and/or 

S+C % Hom

1 24 24 X 

2 61 45 X X X X X 3 10 10 X X 4 3 2 X X 15 9 7 X X 6 10 8 X X 7 22 20 

X 

(sole source) X 

8 25 21 X X X X X 9 72 59 X X X X X 

10 12 11 X X 11 48 44 X X X X X 12 26 26 X X X X X 13 8 6 X X 14 6 5 X X 15 62 52 X X X X X 

16 20 20 

X 

(sole source) X 

17 21 19 X X X X X 18 6 6 X X X 19 12 12 

X 

(sole source) X 

20 11 10 X X X 21 6 6 X X 122 13 8 X X 23 20 17 X X X X 24 35 31 X X 25 17 12 X X 26 64 30 X X X X 27 21 19 no info 28 18 18 X X X 

# of programs / persons 652 558 15 6 9 7 17 8 16 Percentage 53.6% 21.4% 32.1% 25.0% 60.7% 28.6% 57.1% 
Sources of Housing Subsidy 

Columns 3-7 of Table 3.1 gives a breakdown of the different types of housing subsidies 

held by residents of the 28 permanent housing programs. Fifteen of the 28 permanent 

housing programs (54%) reported to have residents receiving housing subsidies from 

HUD’s SHP, six programs (21%) reported housing subsidies from the S+C program, 

seven programs (25%) reported housing subsidies from other HUD programs

9

, and nine 

programs (32%) reported having residents with HUD-Section 8 certificates. Only eight 

programs (30%) reported having no federal housing subsidies for any of their clients. 

(See Table 3.1) 

A closer look at the funding sources reveals that only three permanent housing programs 

reported having all their clients with one source of HUD housing subsidy, all with 

subsidies from SHP.10 In contrast, most of the HUD-funded permanent housing 

programs reported having other sources of housing subsidies for some of their residents, 

including Section 8 and OMH-funded subsidies. In fact, some of the larger permanent 

housing programs started as smaller programs with local funding only (that is, OMH 

housing subsidies). Providers of these programs then contracted with HUD via the S+C 

or SHP funding mechanism and took in permanent housing residents with homelessdesignated housing subsidies.11 For example, the majority of residents in one permanent 

housing program held HUD-SHP subsidies and lived in seven different housing sites 

while the minority of the program residents has OMH-funded housing subsidies. In 

contrast, two programs were targeted exclusively for homeless mentally ill clients but 

were funded through subsidies from the local government and received no HUD 

subsidies. 

Ownership of Housing Units 

The 1260 Housing Development Corporation (1260 HDC) was the major provider of 

housing units for permanent housing residents in Philadelphia. As mentioned above, the 

1260 HDC was established with 125 Section 8 vouchers designated for persons with 

serious mental illness allotted by HUD as part of the RWJ Program. By 2003, the 1260 

HDC had become the owner of more than 1,000 units and 90 buildings in the city and had 

expanded its tenancy base to individuals with other disabilities as well as market tenants. 

9 Unfortunately, providers from the seven programs did not specify what the other HUD programs were. 
 10 It is not clear as to why two of the three programs funded exclusively through HUD’S SHP program do
 

not serve an exclusively homeless population, a program eligibility requirement. It should be noted,
 

however, that the percent of permanent housing participants who ever experienced homelessness was based 
 

on self-reports, which were known to be susceptible to recall bias. One of the three programs did not have 
 

residents participate in the NIMH-funded study.
 11 Formerly homeless permanent housing residents assisted under the S+C and Supportive Housing 
 

Programs cannot port their subsidies outside the community. Some funded under the S+C were able to
 

obtain regular Section 8 vouchers and, therefore, returned the subsidy to the provider. In such an instance, 
 

the AAS would find another eligible resident who satisfied the eligibility criteria of the S+C program.
 

26 
Among 556 current permanent housing residents who had valid address information12, 

the majority (57%) lived in apartments that were either owned or master-leased by the 

1260 HDC. About one-quarter (23%) of permanent housing residents lived in housing 

units that were owned/managed by market realtors or private landlords, which were 

master-leased via the residential support teams. For both the 1260 HDC and residential 

support programs, master-leasing from market realtors or private landlords entails the 

signing of the lease by the provider with the realtors or landlords and then sub-leasing the 

units from the provider to permanent housing residents. Permanent housing residents 

under the master-leasing condition sign their rental contract with and pay monthly rent to 

their provider (either 1260 HDC or the residential support team). A few mental health 

agencies (four agencies) owned and managed their own apartment buildings for 

consumers served by their residential support teams (a total of nine teams), providing 

housing units to another 20% of permanent housing residents. 

Neighborhood characteristics of housing units 

The 556 permanent housing residents lived at 170 unique addresses and in 113 census 

block-groups in the city.13 As Figure 3.1 shows, 73% of the permanent housing residents 

were located in five geographic areas in the city, including West Philadelphia, Near 

Northeast, Lower North Philadelphia, Center City and the Far Northeast. Although 

Center City ranks only fourth in the number of permanent housing residents, substantial 

clustering of permanent housing residents in Center City was observed, due to its smaller 

size relative to other geographic areas. Most of the permanent housing residents in West 

Philadelphia were clustered in University City, a neighborhood comprised of multiple 

block-groups, and four colleges or universities (University of Pennsylvania and Drexel 

University), Philadelphia University of the Sciences and the Restaurant School. 

A comparison was made between the neighborhood characteristics of the permanent 

housing residents and the city population (1.518 million people) using census blockgroup data (Stanhope and Wong 2005; Stanhope, Wong and Hillier 2005).14 

Neighborhood characteristics include median household income, proportion of renters, 

crime rate, and the extent of racial and income diversity. The average median household 

income of the block-groups where permanent housing residents lived was $27,214, 

compared to the $31,990 of the city. Permanent housing residents also lived in 

neighborhoods with a higher proportion of renters (a mean of 0.57, compared to 0.39 of 

the city average) and with a higher crime rate (mean crime rate of 85.89 per 1000 people, 

compared to 67.06 per 1000 people in the city overall). There is, however, a higher level 

of racial diversity (Index of Qualitative Variation [IQV])

15 of 0.50 for permanent housing 

12 One of the two permanent housing residents with no address information was reported missing and the 

other was in prison. 13 Block-groups are census units comprising of several street blocks. A census tract is comprised of roughly 

five block-groups. In Philadelphia, there are 381 census tracts and 1816 block-groups. A block-group has 

an average population of 840 persons. 14 Because permanent housing is considered “normalized” and permanent housing, we found the 

comparison with the overall city population to be appropriate. 15 IQV is a ratio of the amount of variation actually observed in race/income distribution of a block group 

to the maximum variation that could exist in the race/income distribution. Race and income distributions 

27 
residents compared to 0.42 for the general population) and income diversity (IQV of 0.92 

for permanent housing residents compared to 0.82 for the general population) in the 

block-groups where permanent housing residents live than the general population. All 

the above-stated differences between permanent housing residents and the general 

population are significant at the 0.05 level using one-sample t-tests. 

In addition to neighborhood characteristics, access to 25 different types of community 

resources (including health care facilities, commercial establishments, government 

offices, gardens, faith-based organizations, and social and cultural organizations) were 

measured within a half-mile radius of the 556 housing units of permanent housing 

residents and compared to a control group of 500 units selected randomly from the city’s 

housing stock. Results suggest that permanent housing residents were living in housing 

units with significantly higher levels of resource accessibility than the control group (t = 

8.683, p < .0001). 

Residential Support Services Characteristics 

Twenty-eight residential support teams, which are identical to permanent housing 

programs, provide support services to maintain independent living in permanent housing. 

The overall mission of these teams is to enable permanent housing residents to live 

independently in the community through skills development and by linking consumers to 

community-based mental health services. They began operation at various times from 

1986 to 2001. 

We classify permanent housing programs as either “scattered-site” or “clustered-site” 

programs based on the dispersion of housing units. Clustered site programs are those 

serving all permanent housing residents within one building site or multiple buildings 

clustered in a single neighborhood. Scattered sites serve permanent housing residents in 

various neighborhoods in the City. According to this definition, 12 of the 28 permanent 

housing programs were scattered-site programs, and 16 were clustered-site programs. 

The total capacity and occupancy of the 12 scattered-site teams was 407 and 329, 

compared to 245 and 229 for the 16 clustered-site teams. Scattered-site support teams 

served, on average, more consumers than clustered-site teams (27 consumers for 

scattered site compared to 14 consumers for clustered-site).16 

Program capacity and occupancy vary substantially among the 28 residential support 

teams, ranging from three to 72 and from two to 62 for occupancy (refer to column 1-2 of 

Table 3.1). Staffing information on 27 of the 28 teams was available through the 

provider interviews. The 27 teams employed a total of 72 full-time and 129 part-time 

staff members. After adjusting the differential efforts of full-time and part-time staff, the 

are, respectively, constructed as two 3-category variables. The categories for race are: white, black, and 

others; the categories for income are: low (< 15,000), medium (15,000- 44,999), high (50,000 & higher). 16 The statute for the Permanent Housing program defines permanent housing as community-based housing 

that provides long-term housing and supportive services for not more than eight homeless people with 

disabilities in a single structure of contiguous structures or up to 16 such persons, but only if not more than 

20 percent of the units in a structure are designated for such persons. The dispersion of housing sites is 

consistent with the statute for Permanent Housing program. 

28 
total number of full-time equivalent staff for the 27 teams is 115. Considerable variation 

exists in the intensity of staffing among the 27 teams, with the number of consumers per 

staff person ranging from 1.05 to 11.33. The mean number of permanent housing 

residents per staff person was 5.48. More than half (56%) of staff members are 

residential case managers, specialists, or counselors, 29% were program supervisors or 

directors, 9% were administrative assistants/secretarial staff or maintenance staff, and 6% 

are other staff, including drug and alcohol specialists, social workers, and medical staff. 

Housing Preference of Permanent Housing Residents 

In-person interviews with 252 current permanent housing residents provided information 

on housing preference. Housing preference of permanent housing residents is an 

important variable to be considered in this study because prior research has found 

perceived consumer choice to be a significant predictor of success in housing through its 

positive association with housing satisfaction and residential stability (Ridgway and Rapp 

1997; Tanzman 1993; Tsemberis et al. 2003). Specific to this project, housing preference 

information gives some idea about permanent housing residents’ desire to move to 

another residence or have other living arrangements (for example, living alone or living 

with family members) should they be given the opportunity to do so. 

When permanent housing residents were asked whether or not they would like to be 

living in their current place a year from now, only 40% answered affirmatively. 

Moreover, an overwhelming majority (81%) of permanent housing residents in the study 

expressed the preference not to live with other mental health consumers, while 10.6% 

indicated that they would and 8.6% that it did not matter to them. Nearly half (46%) of 

the permanent housing consumers expressed a preference to live with family members, 

including spouse/romantic/partner/significant other, adult family members or relatives, 

and consumers’ own children under 18 years of age. 

How do the housing preferences of permanent housing residents compare to their current 

living situation? Table 3.2 provides answer to this question. The table is split into two 

parts. The first cross-tabulates current living situation with preferred living situation in 

regard to living with other mental health consumers. The second cross-tabulates current 

living situation with preferred living situation in regard to living with family members. 

We did not include living with friends and other non-family members because of the 

small number of residents who were either currently living or expressed a preference for 

living with friends and other non-family members (other than mental health consumers). 

29 
TABLE 3.2: CURRENT LIVING SITUATION & PREFERRED LIVING 

SITUATION (N = 252) 

A. WITH OTHER MENTAL HEALTH CONSUMERS 

Current Living Situation 

Preferred Living Situation 

With other mental 

health consumers 

Not with other mental 

health consumers 

Total for preferred 

living situation 

With other mental health consumers 16 (29.6%) 10 (5.2%) 26 (10.6%) 

Not with other mental health 

consumers 32 (55.3%) 166 (86.9%) 198 (80.8%) 

Does not matter 6 (19.1%) 25 (7.9%) 21 (8.6%) 

Total 54 (22.0%) 191 (78.0%) 245 (100%) 

Chi-square = 28.11; p < .0001 
 

Note that 7 observations have missing data. 
 

B. WITH FAMILY MEMBERS 

Current Living Situation 

Preferred Living Situation With family members 

Not with family 

members 

Total for preferred 

living situation 

With family members 34 (85.0%) 82 (38.7%) 116 (46.0%) 

Not with family members 6 (15.0%) 130 (61.3%) 136 (54.0%) 

Total 40 (15.9%) 212 (84.1%) 252 (100.0%) 

Chi-square = 29.06; p < .0001 

As the data indicate, permanent housing residents who were currently living with other 

mental health consumers were more likely than those who were not to express a 

preference to live with other consumers. In a similar fashion, permanent housing 

residents who were currently living with family members were more likely than those 

who were not to express a preference to live with family members. The chi-square 

statistics of the two sets of associations are both significant at the 0.0001 level. Despite 

the significant and positive association between current and preferred living situations in 

regard to other mental health consumers, it is important to note that more than half (55%) 

of permanent housing residents who were currently living with other consumers preferred 

not to do so. Likewise, among those permanent housing residents who were not currently 

living with family members, more than one-third (39%) would prefer to do so. Overall, 

our findings on housing preferences underscore the significance of consumer choice in 

the development of permanent housing programs.17 

17 It is important to note that the Housing First model, which places an emphasis on housing choice and 

consumer preference, has been proposed as an alternative to more clinically managed residential programs 

(Hopper & Barrow, 2003; Tsemberis, 1999). In Philadelphia, two permanent housing programs adopting 

the Housing First model have been operating after the onset of this study. 

30
 
The housing preference data analyzed above conclude the description of characteristics 

central to the operation of permanent housing programs in Philadelphia based on the 

NIMH-funded study. In the next section, we will be reporting on the retrospective 

tracking data collected from the current research project. 

Departures from Permanent Housing: Incidence and Timing 

The findings presented in this section address one of the key questions asked in this 

project: Is permanent housing a form of housing that permits long-term residency but in 

practice looks like transitional housing but for a narrower eligible population? To 

answer this question, we used the retrospective tracking data collected from the 

integrated longitudinal database.

18 Recall from Chapter 2 that all 943 persons who 

participated in Philadelphia’s permanent housing programs between January 1, 2001 and 

July 15, 2004 and whose admission date was before December 31, 2003 were selected 

into the retrospective sample. Leavers were designated as individuals who left permanent 

housing between January 1, 2003 and July 15, 2004, while stayers were those who were 

currently in permanent housing as of July 15, 2004. 

Incidence of Discharges from and Admissions to Permanent Housing (Entire 

Retrospective Sample) 

The integrated longitudinal tracking data indicate that among the 943 permanent housing 

residents, 385 (41%) are leavers and 558 (59%) are stayers. The numbers of leavers for 

the calendar years 2001, 2002, and 2003, are, respectively, 109, 123, and 107. The 

number of leavers who left between January 1, 2004 and July 15, 2004 is 46. 

Table 3.3 breaks down the tracking data into three groupings: the number of current 

permanent housing residents on the first day (January 1) of the calendar year, the number 

of admissions during the year and the number of discharges during the year for 2001, 

2002, 2003, and 2004 (up to July 15). In each of the three years (2001 – 2003) when 

complete data are available, the number of admissions exceeds the number of discharges, 

resulting in an increase in occupancy for permanent housing programs. As column 1 of 

the table shows, the number of current residents at the start of the calendar year increased 

by 20 percent from 505 persons in 2001 to 604 persons in 2004. 

18 We used the retrospective tracking data because of the complete coverage of all leavers and stayers in the 

three and a half years of the project. Note that the in-person interview data only tracked a sub-sample of the 

leavers who departed from permanent housing after January 1, 2003 and who agreed to participate in the 

prospective tracking study. 

31 
TABLE 3.3: DATA ON CURRENT RESIDENTS, ADMISSIONS & DISCHARGES 
 

Calendar Year 

No. of current residents on 

Jan. 1 of the year 

No. of admissions 

during the year 

No. of departures 

during the year 

2001 505 152 109 (16.6%)

19 

2002 548 134 123 (18.0%) 

2003 559 152 107 (15.1%) 

2004 (up to July, 2004) 604 Figures not available 46 (N.A.) 

Types of Discharges from Permanent Housing 

Table 3.4 reports discharges by type from permanent housing as recorded in the 

“disposition codes” in the integrated longitudinal database. These disposition codes are 

reported by the provider agency at client departure and entered in the database by the 

City. The most frequently cited destination of discharge is from permanent housing to 

independent and other community arrangements, including living with spouse/significant 

others, family members, and friends (30.4%). Interestingly, a substantial portion of 

permanent housing discharges are without any specified destination or with the 

whereabouts of the leavers unknown to the permanent housing program (29.6%). Nearly 

one-quarter (23.6%) of the 385 leavers were discharged to congregate community-based 

settings, signaling more intensive level of care and supervision. About five percent of the 

discharges were due to the death of the resident. Fewer than five percent of the 

discharges were recorded as the following: hospital settings (4.7%), correctional settings 

(3.4%), and homelessness (2.9%). 

19 Percent of discharges based on total of current residents as of January 1st of the year plus admissions 

during the same year. 

32
 
TABLE 3.4: TYPES OF PERMANENT HOUSING DISCHARGES
 

Type of Discharge Frequency Percent 

Independent & other community arrangements 117 30.39

 Living alone/independent 71 18.44

 Site moved to new address 4 1.04

 Spouse/significant other 11 2.86

 Living with parent/guardian 10 2.60

 Other friends/family 21 5.45 

Congregate settings 91 23.64

 MH residential program 61 15.84

 Dual diagnosis residential program 8 2.08

 Drug and alcohol residential program 10 2.60

 Boarding home 11 2.86

 Nursing home 1 0.26 

Hospital settings 18 4.68

 Extended acute care unit 7 1.82

 Community inpatient 9 2.34

 State hospital 2 0.52

 Correctional institution 13 3.38 

Homelessness 11 2.86

 Shelter 9 2.34

 Street 2 0.52 

Other/unknown 114 29.61

 Other unspecified location 26 6.75

 Whereabouts unknown 88 22.86 

Deaths 21 5.45 

Total 385 100.00 

Timing of Discharges from Permanent Housing for a Sub-sample of Three Entering 

Cohorts 

The analysis of the timing of leaving permanent housing is based on a sub-sample of 

three cohorts entering permanent housing in the calendar years of 2001, 2002, and 2003. 

Analysis based on entering cohorts yields more accurate estimates of the timing of 

discharges than using the entire retrospective sample of 943 residents. This is because 

the absence of information on leavers who entered at the same time as permanent housing 

residents currently in permanent housing in January 2001 but who left before the start 

33 
date of study leads to an overestimate of the length of stay in permanent housing among 

stayers and yields inaccurate estimates of the incidence of leaving. 

Table 3.5 provides the percentages of the three entering cohorts who left permanent 

housing at five cumulative time intervals: 1) within 6 months; 2) within 12 months; 3) 

within 18 months, 4) within 24 months, and 5) within 30 months. Because of the 

variation in coverage of information between the admission dates of members of the three 

cohorts and the date of recording the last departure (which is July 6, 2004), the duration 

of tracking leavers varies for each cohort. For example, residents who entered permanent 

housing in 2001 have a minimum tracking period of two and a half years, whereas 

residents who entered in 2003 have a minimum tracking period of six months. 

TABLE 3.5 PATTERNS OF DISCHARGE FOR THREE ENTERING COHORTS 

Cumulative Time Interval 

2001 cohor 

(n=152) 

t 2002 cohor 

(n=134) 

t 2003 cohort 

(n=152) 

Percent left within 6 months 11.18 11.19 6.58 

Percent left within 12 months 24.34 24.63 N.A. 

Percent left within 18 months 33.55 33.58 N.A. 

Percent left within 24 months 41.45 N.A. N.A. 

Percent left within 30 months 48.03 N.A. N.A. 

As the data indicate, the timing of departure for the 2001 and 2002 cohorts is almost 

identical for the first three time intervals. For each of the two cohorts, about 11 percent 

left permanent housing within six months, close to a quarter left within one year, and 

about one-third left within 18 months. Among residents of the 2001 cohort, for which 

tracking data are available for at least 30 months, two in five residents left permanent 

housing within 24 months and nearly one-half left within 30 months. 

From the table, one can observe that there is a lower incidence of leaving during the first 

six months for those who entered permanent housing in 2003. Due to the limited length 

of observation, incidence of leaving for beyond six months is unavailable. 

Summary 

The development of permanent housing programs in Philadelphia, Pennsylvania, 

coincides with a period of time when HUD initiated, expanded, and maintained its 

funding for permanent housing programs for homeless persons with serious mental 

illness. The community residential system under the administration of Philadelphia’s 

OMH has been successful in leveraging resources from HUD and the local government to 

expand its permanent housing programs to meet the housing and service needs of its 

target population. As a result, a majority of the 28 permanent housing programs in the 

mental health system rely partially or entirely on HUD-funded housing subsidies. Most 

of the permanent housing residents reported a prior history of homelessness. 

34 
Permanent housing programs embrace a variety of approaches that differ in housing and 

service characteristics. Notwithstanding the between-program differences, provision of 

residential support to enable permanent housing residents to live independently in the 

community through skills development and by linking consumers to community-based 

mental health services is the defining feature of the permanent housing programs. The 

“support” component of permanent housing programs is seen as critical for facilitating 

the residential stability of their residents, as well as enhancing their integration into the 

community. The residential support teams aside, the 1260 HDC is another key player in 

the development of permanent housing programs. The remarkable expansion of the 1260 

HDC in the nearly two decades since its founding has supplied permanent housing 

residents with a substantial pool of decent and affordable rental units and provided a 

reasonable degree of housing choice for these residents. 

Permanent housing residents lived in 113 census block-groups out of 1,816, with the 

majority of them distributed in 5 areas of the city. Compared with the Philadelphia 

general population, permanent housing residents lived in neighborhoods with a higher 

degree of racial and income diversity and have access to more community resources. 

Although permanent housing neighborhoods have lower median household income, 

higher crime rates, and proportionately more renters than an average Philadelphia 

neighborhood, it is important to note most of permanent housing neighborhoods are not 

located in areas of the city with the highest levels of social and economic distress 

(Stanhope and Wong 2005). 

Although permanent housing in Philadelphia is a long-term housing arrangement for a 

significant portion of permanent housing residents, the incidence of leaving is about 30% 

during the first 18 months and 50% after 30 months of residence. Information on 

permanent housing residents’ housing preference provides some plausible interpretation 

of leaving, especially those under favorable conditions when residents are given a choice. 

It is intriguing that more than half of current permanent housing residents would like to 

be living in a different place a year from now. Moreover, nearly half of permanent 

housing residents would like to be living with family members and other relations (other 

than unrelated mental health consumers), despite the fact that less than one in six was 

currently able to do so. The housing preference expressed by residents is indicative of 

their intention to leave permanent housing programs or move on to another residence or 

living arrangement should an alternative situation arises. The other side of the story is 

that some permanent housing residents have to leave because of an undesirable situation. 

In the next chapter, we will explore the different circumstances of leaving among residents 

who departed permanent housing. We will identify and examine both positive and negative 

scenarios of leaving, as well as, the post-permanent housing careers of leavers. 

35 
36
 
CHAPTER 4: LEAVING PERMANENT HOUSING—CIRCUMSTANCES OF 

LEAVING AND THE POST-PERMANENT HOUSING CAREERS OF LEAVERS 

Overview 

In the previous chapter, we found that departure from permanent supportive housing is a 

relatively common phenomenon among permanent housing residents with serious mental 

illness in Philadelphia. Using data drawn primarily from the prospective tracking sample 

of 96 leavers, this chapter builds on this finding by providing a detailed account of the 

circumstances surrounding their departure from permanent housing and the post-permanent 

housing careers of these leavers. 

The chapter is organized in two sections. The first describes the circumstances of leaving 

among the members of the prospective tracking sample. Specifically, we look at the 

destinations to which the 96 leavers were discharged and their living situation at the time 

of departure. Based on the leavers’ and their residential staff’s responses regarding the 

circumstances of leaving, two groups of leavers—voluntary and involuntary leavers—are 

identified. We then report what factors appear to differentiate voluntary and involuntary 

leavers. To complement the quantitative findings, we present a number of “leaver” 

scenarios based on a review of the qualitative responses of leavers. 

The second section of the chapter examines the post-permanent housing careers of leavers. 

The quantitative data used in describing the post-permanent housing careers are drawn 

from both the prospective tracking sample and the retrospective tracking sample (recall that 

385 residents left permanent housing from January 1, 2001 through July 15, 2004). 

Whereas the prospective tracking data focus on the living situations of leavers over time, 

retrospective tracking data provides information on service use (based on administrative 

data) after permanent housing residents left their programs. To augment the quantitative 

information on post-permanent housing careers, qualitative characterization of leavers’ 

post-permanent housing careers is explored using excerpts from notes generated from the 

tracking interviews of study participants. 

Overall, we find that leaving permanent housing is multidimensional both in terms of the 

reasons for leaving and the post-permanent housing residential career. The postpermanent housing residence of the majority of leavers tracked in the prospective sample 

required a greater level of independence than was required in the permanent housing 

itself. Those who did not move to more independent living appeared to maintain 

residential stability – only 10% had to transition into other housing after their initial postpermanent housing residence. 

Leavers can be categorized into multiple sub-categories that are related to their skills to 

live independently and their need for greater support and service when they resided in 

permanent housing. Not surprisingly, those who have less independent living skills and 

need greater support generally have less favorable housing experiences after leaving 

permanent housing. 

37 
Circumstances of Leaving 

Destinations of Departure from Permanent Housing and Living Situation upon 

Departure 

Table 4.1 describes the type of residence and various indicators of living situation 

reported by 96 participants at the baseline interview. The findings suggest a rather 

favorable picture of departure from permanent housing among the 96 participants. About 

two-thirds (66%) of the sample were in regular community living situations in an 

apartment or a house with or without subsidy, in single room occupancy (SRO), or 

sharing a residence with family or friends. One-quarter (25%) of the sample departed to 

congregate community residences, signaling more intensive level of care and supervision 

than permanent housing programs, and only one in fourteen (7%) of the sample reported 

to be homeless or in an institution. Of course, these positive findings are circumscribed 

somewhat by the fact that we were able to track only a subset of the leaver population, 

even for the baseline interviews. 

TABLE 4.1: BASELINE RESIDENCE & LIVING CIRCUMSTANCES AFTER 

LEAVING PERMANENT HOUSING 

Variable Category Baseline 

(N= 96) 

Type of current 

residence 

Apt./House w/subsidy 

Apt./House w/o subsidy 

Community Residence 

Single Room Occupancy 

Other Residence 

Share residence w/family or friends 

Detox/Drug and Alcohol Rehab 

Institutions 

Homeless 

55% 

2% 

11% 

2% 

8% 

7% 

6% 

1% 

6% 

Feelings about current 

residence 

Delighted/Pleased 

Mixed/Mostly Satisfied 

Terrible/Unhappy/Mostly Dissatisfied 

43% 

40% 

17% 

Assessment about 

quality of life 

Delighted/Pleased 

Mixed/Mostly Satisfied 

Terrible/Unhappy/Mostly Dissatisfied 

51% 

39% 

10% 

Employment Received income from employment 21% 

Volunteer work Did volunteer work 26% 

Day program Attended a structured day program 37% 

Mental health service Used a therapist 63% 

Supplemental Security 

Income 

Received supplemental security income 66% 

Food Stamps Received Food Stamps 21% 

Monthly income Mean monthly income $660 

Monthly rent Mean monthly rental paid $203 

Some of the aforementioned destinations would appear to represent a positive outcome, 

such as an apartment or house, and others a negative outcome, such as homelessness or 

38 
prison/jail. However, the favorability of all destinations is not equally clear. The followup surveys included a question about the leaver’s feelings about his/her current residence. 

A seven-point semantic scale ranging from “delighted” to “terrible” (delighted, pleased, 

mostly satisfied, mixed, mostly dissatisfied, unhappy and terrible) was employed. 

Focusing on the most satisfied category (delighted/pleased) provides some insight on 

how the leaver categorizes his/her residence. The most satisfied leavers are those living 

alone without a subsidy, and the least satisfied are those living in institutions. However, 

it is perhaps noteworthy, even given the small numbers involved, that it appears a greater 

proportion of leavers are satisfied with “other residence”, for example board and care 

home, nursing home and other (53% vs. 19%) and “single room occupancy” (SRO) (48% 

vs. 5%) than are dissatisfied. Conversely, an equal proportion of leavers are satisfied and 

dissatisfied with “sharing a residence” (22% vs. 26%). Half of all those in drug/rehab 

were satisfied (52%), and the other half considered it a neutral experience (48%). No one 

indicated dissatisfaction with his/her presence in a drug/rehab facility. 

As the data in Table 4.1 indicate, since leaving permanent housing, nearly two-thirds 

(63%) were currently engaged in mental health services through seeing a therapist. Less 

than half of the sample was involved in the following activities: 37% attended a day 

program for mental health consumers; 21% engaged in paid employment; and 26% 

engaged in volunteer work. Most of the 96 permanent housing leavers were receiving 

income support at the baseline interview after leaving permanent housing—66% received 

Supplemental Security Income (SSI) and 21% received Food Stamp. Finally, as a group, 

the retrospective sample was generally satisfied after leaving permanent housing. Only 

10% reported to be feeling mostly dissatisfied with their quality of life, and 17% reported 

dissatisfaction with their current residence. 

Identification of Subgroups of Leavers—Voluntary and Involuntary Leavers 

Two subgroups of leavers—voluntary and involuntary leavers—were identified based on 

the leavers’ and program staff’s characterization of the circumstances surrounding the 

departure from permanent housing. Voluntary leavers are, in general, permanent housing 

residents who have plans to leave, find their leaving desirable, and have the concurrence 

and support of the housing and program support staff in that opinion. Involuntary leavers 

are those who were asked/forced to leave the permanent housing for a variety of reasons; 

leaving was the choice of the housing provider and the program staff rather than the 

resident. 

There were several instances in which the leaver categorized his/her leaving as voluntary 

and program staff categorized it as involuntary. In those cases, the leave was categorized 

as involuntary per the program staff’s assessment. There were no instances in which the 

program staff categorized the leave as voluntary but the leaver categorized it as 

involuntary. 

Using the above definition, 59 (61%) of the leavers were categorized as voluntary leavers 

and 37 (39%) were categorized as involuntary leavers. The two groups of leavers do not 

differ in basic demographics, including age, gender and race. The median age of the 96 

39 
leavers is the mid-forties, and there were more females (59%) than males (41%). Twothirds of the sample was Black/African American, slightly more than one-quarter (27%) 

was White, and 6% was of other races. 

Comparison of Voluntary and Involuntary Leavers 

Four key attributes pertaining to the circumstances surrounding the departure of 

permanent housing residents were compared between voluntary and involuntary leavers: 

(1) reasons given for leaving; (2) behavioral characteristics of leavers; (3) leavers’ level 

of skills in independent living, and 4) support and services received from residential 

support staff during leavers’ permanent housing tenure. 

Reasons for Leaving Permanent Housing—Eleven possible reasons for leaving 

permanent housing were posed by the interviewers to help distinguish among the various 

circumstances of departure.20 Each interviewee could provide multiple reasons for 

discharge. Of the list of reasons given, “opportunity to move to more desirable housing” 

was the most frequently mentioned reason, with nearly half of the leavers endorsing this 

reason. The next two most frequently mentioned reasons were “got sick, was 

hospitalized” and “asked to leave” (each was selected by 31% of leavers). Approximately 

one in five leavers, respectively, mentioned “program wasn’t what I expected” (20%) and 

“got high/drunk” (18%) as the reasons for leaving. This is followed by “rules too strict” 

(15%) and “did not get along with roommate or other residents” (10%). Less than 10% 

of leavers mentioned the following as reasons for leaving: “got upset, damaged property” 

(8%), “got in trouble, was arrested” (6%), “residence too far from public transportation” 

(5%), and “got upset, hurt someone” (4%). 

Comparing voluntary and involuntary leavers indicates statistically significant differences 

between the two groups for four out of the 11 reasons for leaving permanent housing 

(panel 1 of Table 4.2). Consistent with the expectation that involuntary leavers left 

permanent housing for more adverse circumstances, these leavers were more likely to 

have been asked to leave housing, got high or drunk, and got sick and were hospitalized. 

In contrast, nearly two-thirds (63%) of voluntary leavers, compared to one-fourth (24%) 

of involuntary leavers, perceived leaving permanent housing as an opportunity to move to 

more desirable housing. 

20 The questions regarding “reason for leaving” were structured differently for the program staff. The 

program staff was asked an open-ended question about the circumstances of leaving and a close-ended 

question (Yes or No) about whether the “leave” was voluntary or non-voluntary. 

40 
TABLE 4.2: COMPARISON OF ATTRIBUTES OF VOLUNTARY & 

INVOLUNTARY LEAVERS 

Voluntary Involuntary All 

leavers 

Total OpportunitySituational 

Seeker Leaver 

Variables/Items (N = 59) (N = 38) (N = 21) (N= 37) (N = 96) 

Reasons for Leaving (% indicated “yes” by client) 

Opportunity to move to more desirable housing*** 63% 76% 38% 24% 48% 

Asked to leave

*** 15% 5% 33% 57% 31% 

Got sick, was hospitalized** 20% 8% 43% 47% 31% 

Got high/drunk** 10% 5% 19% 30% 18% 

Behavioral Characteristics (% indicated “yes” as 

reported by provider) 

Psychiatric diagnosis of schizophrenia

** 34% 39% 21% 67% 47% 

Psychiatric diagnosis of bipolar disorder

*

 36% 45% 14% 10% 26% 

Substance abuse

** 15% 15% 13% 47% 27% 

Assaultive behavior* 0% 0% 0% 10% 4% 

Other antisocial behavior

** 0% 0% 0% 17% 6% 

Level of Independent Living Skills (% rated by 

provider as never/rarely able to perform the task) 

Food management*** 4% 3% 7% 37% 17% 

Money management*** 8% 6% 13% 47% 23% 

Planning & organizing time

***

 8% 9% 7% 43% 22% 

Medication management*** 6% 3% 13% 37% 18% 

Self-care & self-preservation*** 4% 3% 7% 7% 5% 

Use of public transportation*** 6% 3% 13% 20% 12% 

Support and Services from Staff (% indicating more 

intensive support than an average mental health 

client as rated by provider) 

Transportation*** 13% 3% 33% 20% 15% 

Dealing with crisis*** 23% 18% 33% 60% 37% 

Making appointments for medical/psychiatric care** 19% 9% 40% 50% 31% 

Connecting with social services** 13% 12% 13% 43% 24% 

Dealing with stress and emotional upset** 25% 18% 40% 53% 36% 

Employability/employment skills** 13% 15% 7% 34% 21% 

Medication management* 13% 6% 27% 43% 24% 

Development of natural support networks* 10% 6% 20% 37% 21% 

Food management* 8% 3% 20% 38% 19% 

Self and personal care* 15% 9% 27% 40% 24% 

Note: Chi-square; Statistical significance: # 

p < .10. * p < .05. ** p < .01. *** p < .001. 

Behavioral Characteristics of Leavers—Residential support staff was asked to provide 

information on the behavioral characteristics of permanent housing leavers. These 

behavioral characteristics include psychiatric diagnosis and problematic behaviors that 

41 
are considered to be risk factors for leaving permanent housing. As the second panel of 

Table 4.2 indicates, involuntary leavers were more likely to have a diagnosis of 

schizophrenia but less likely to have one of bipolar disorder. Involuntary leavers were 

also three times more likely to have a substance abuse problem than voluntary leavers. 

Moreover, while none of the 59 voluntary leavers were rated as having problem with 

assaultive and other anti-social behavior, 10% and 17%, respectively, of involuntary 

leavers were reported to have these undesirable behaviors while in permanent housing. 

Level of Skills in Independent Living of Leavers—Six areas of life skills considered 

critical to the maintenance of independent living were compared between voluntary 

leavers and involuntary leavers. These include food management (that is, plans personal 

menus, purchases food, plans meals, and cleans-up, and so forth), money management, 

planning and organizing time, medication management, self-care (that is., bathes, 

grooms, toilets, dresses, ambulates, and so forth) and self-preservation (responds 

appropriately to personal danger), and use of public transportation. The skills were rated 

by residential support staff with the response set of: (1) often or always able to perform 

the task; (2) sometimes able to perform the task; and (3) never or rarely able to perform 

the task. Only the percentages of those who never or rarely able to perform the various 

tasks were reported for the sake of economy. 

The findings (refer to panel 3 of Table 4.2) indicate striking differences between 

voluntary and involuntary leavers in all six areas of independent living skills. Whereas 

less than 10% of voluntary leavers were rated as never or rarely able to perform any of 

the six tasks, more than one-third of involuntary leavers were rated as never or rarely able 

to perform four of the living skill tasks. 

Support and Services from Residential Support Staff— The higher proportion of 

involuntary leavers never or rarely able to perform the tasks associated with the six areas 

of independent living compared to voluntary leavers, might have meant that involuntary 

leavers would receive more intensive support from the residential staff. Residential 

support staff is expected after all to adapt and deliver support based on the unique and 

individual needs of permanent housing residents. For each of the 96 leavers, a residential 

support staff member was asked to rate the degree to which different types of support and 

services were provided. The response choices were constructed in reference to an 

“average” client. These choices included: (1) much less or slightly less than average, (2) 

average, and (3) much more or slightly more than average. We compared the percentages 

of voluntary and involuntary leavers whom residential support staff reported to have 

provided more intensive support during their permanent housing tenure (that is, 

percentages that fall into the “much more or slightly more than average” category). 

Consistent with our expectation, involuntary leavers were more likely to receive intensive 

support from residential support staff in all 11 areas of support and services than 

voluntary leavers (refer to Panel 4 of Table 4.2). Indeed, in all but one of the areas, 

involuntary leavers were more than twice as likely to receive intensive support than 

voluntary leavers. For example, three in five involuntary leavers (60%) received support 

in dealing with crisis that is much more or slightly more than an average client (the 

42 
highest percentage among the 11 items). In contrast, one in four voluntary leavers (23%) 

received such a level of support. Whereas less than one in ten (8%) of voluntary leavers 

received more intensive support from their residential support staff with regard to food 

management, nearly two in five (38%) of involuntary leavers were in need of such level 

of support. Overall, voluntary leavers appear to be more independent than their 

involuntary counterparts and, consequently, received less support and services from 

program staff. 

Scenarios of Leaving 

We created these scenarios of leaving permanent housing based on a systematic review of 

the interview data from the prospective tracking sample. In addition to the responses to 

the close-ended questions, open-ended questions were asked of leavers and residential 

staff to describe the circumstances surrounding departure from permanent housing 

programs. The qualitative responses to the open-ended questions were recorded and 

categorized to construct scenarios of leaving. 

In the following, we present scenarios of leaving for involuntary and voluntary leavers. In 

addition to the involuntary leavers, we split the voluntary leaver category into two 

subcategories, “opportunity seekers” and “situational leavers.” The scenarios for the 

involuntary leavers evidence the challenges of maintaining residential stability; the 

scenarios for the opportunity seekers manifest their intent to continue to improve their 

lives by leaving permanent housing for a residence they perceive will be better for them; 

in contrast, situational leavers find themselves outside permanent housing because 

permanent housing failed in some respect to address their situational needs.21 

Involuntary Leavers—The five scenarios presented below highlight the “vulnerabilities” 

that persons with serious mental illness face in their struggle to maintain residential 

stability. Three participants acknowledged their inability to maintain a drug/alcohol-free 

lifestyle, and two admitted their inability to follow program rules as reasons for departure 

from permanent housing. In three of the five scenarios, environmental factors (drug 

activities in the building, unsavory people and “influenced by the wrong people”) were 

mentioned as contributing to their departures. 

Involuntary Leaver # 1: Anna B. is a 50 year-old female who departed after two years 

and two months stay in permanent housing. Although Anna did mention her 

deteriorating medical conditions, a stroke, she perceived that she had been involuntarily 

discharged because she had hosted too many of the wrong type of visitors. Program staff 

reported that Anna was moved from her apartment to a progressive demand residence 

because she was in need of more medical care. 

21 Thirty-eight (38) of the 59 voluntary leavers are classified as “opportunity seekers” and 21 are classified 

as “situational leavers.” 

43 
Involuntary Leaver # 2: John P. is a 25 year-old male who departed after two years and 

two months stay in a permanent housing program. He admitted that his discharge was 

due to his inability to follow the rules of the permanent housing program. Specifically, 

John was unable or unwilling to manage his money according to the standard set by the 

program. He complained that he felt some of the rules were too strict. In addition, he 

complained that drug activity was going on in the building and was upsetting him. 

Program staff reported that John needed a program with more staff support. They 

reported that he had difficulty managing his medication and had to be constantly pushed 

to meet program requirements. In regard to the building problem, program staff reported 

that John P. had been beaten up and wanted to leave. 

Involuntary Leaver # 3: James J. is a 47 year-old male who resided in permanent housing 

for seven years and two months. According to the participant, he was discharged due to 

alcohol abuse. He admitted that he allowed himself to be influenced by the “wrong 

people” and had been using alcohol on program premises for some time before being 

caught by program staff. The permanent housing program staff reported similar 

discharge reasons— James had been caught drinking and was asked to leave. The staff 

felt he needed a more structured program. He was residing in a detoxification facility 

during the period for which we were able to track him. 

Involuntary Leaver # 4: John R. is a 38 year-old male who resided in permanent housing 

for 18 months. According to the participant, he was discharged because of his substance 

abuse problem. In fact, he was living in a detoxification facility throughout his yearlong 

follow-up period. Also, he admitted that he broke program rules and acknowledged that 

he “did wrong.” Permanent housing program staff reported that John was discharged for 

drug use and for not maintaining cleanliness standards at his apartment. 

Involuntary Leaver # 5: Mary P. is a 42 year-old female who had resided in permanent 

housing for four years. She reported her discharge was due to drug use and was 

voluntary. Residential support staff also reported that Mary was discharged for drug 

abuse but the discharge was involuntary. 

Voluntary Leavers: Opportunity Seekers—“Opportunity seekers” tend to regard 

themselves as “graduates” of a Permanent Housing program, who intend to improve 

themselves and who express hopefulness about their future. Beyond possible differences 

in the physical condition of the new residence, the “opportunity seekers” do not anticipate 

continuing to receive support or services.22 

Opportunity Seeker # 1: Patricia L. is a 54 year-old female who departed after nine years 

in permanent housing. At the baseline interview, she indicated she had graduated from 

the permanent housing program, was compliant with medications and got along well with 

22 Although, these leavers opted to leave permanent housing, HUD’s Permanent Housing program can 

accommodate the independent permanent housing situations described here with the services gradually 

reduced. As long as the client meets, at entry, the criteria of being homeless and disabled, they are an 

eligible recipient of the Permanent Housing program. 

44 
other residents in the program. Program staff reported that Patricia was staying in 

transitional housing preparing her move to independent housing. She had received a 

Section 8 voucher, which would allow her to move into a permanent independent living 

situation. 

Opportunity Seeker # 2: Robert M. is a 56 year-old male who departed after two years 

and four months in permanent housing. At the baseline interview, Robert said he had 

graduated from the permanent housing program and had to move on to better himself. 

Program staff reported he exhibited the skills needed to live in a more independent 

setting. At the time of the study, Robert was living in his own apartment, and a 

caseworker came out to visit him weekly. 

Opportunity Seeker # 3: Linda B. is a 27 year-old female who departed after one year and 

four months in permanent housing. During the initial interview after discharge, she stated 

that overall the program was positive and that she felt that she had been ready to be on 

her own since 2001. Her case manager did not agree with her at the time, and she waited 

until a more opportune time – when she would have more benefits available to her. 

Program staff reported the Linda had wanted her own apartment, and her intensive case 

manager (ICM) helped her find housing elsewhere. The residential support staff regarded 

her case as a positive departure. 

Voluntary “Situational” Leavers—“Situational leavers” depart voluntarily from 

permanent housing programs but under a different set of circumstances than “opportunity 

seekers.” As the following scenarios illustrate, situational leavers reported having health 

problems, believed too much was demanded of them in permanent housing and/or had 

issues with roommates, staff or neighbors. 

Situational Leaver # 1: Barbara E. is a 61 year-old female who departed after three years 

and eight months in permanent housing. She explained her departure primarily in terms 

of a physical health problem. She suffered from a muscle disease that caused her to fall 

and injure herself. She also felt paranoid about falling, so she wanted to go to a nursing 

home. Program staff concurred with Barbara’s assessment. 

Situational Leaver # 2: Michael W. is a 32 year-old male who departed after two years 

and nine months in permanent housing. When interviewed by research staff, he revealed 

that household chore requirements for his apartment were simply too difficult and that 

with him going in and out of the hospital, he felt that a group living situation was the best 

fit for him at this time. Program staff reported that Michael needed more care and moved 

to a more structured facility. 

Situational Leaver # 3: Elizabeth J. is a 54 year-old female who departed after one year 

and eight months in permanent housing. The reason she gave for her leaving permanent 

housing was the demolition of the apartment building where she lived. Program staff 

concurred with her account by reporting that Elizabeth’s former residence was bought by 

45 
Temple University and that the building was demolished and then turned into a parking 

lot. 

Post-Permanent Housing Career of Leavers 

The characterization of the post-permanent housing careers of leavers is based primarily 

on prospective tracking data comprised of a baseline interview with 96 leavers and 

subsequent monthly follow-up contacts. The original plan was that each leaver who 

agreed to participate in the study would complete a baseline survey, and then would be 

contacted monthly for an in-person or telephone interview. Almost no participant, 

however, completed a follow-up survey for each month they were eligible. Therefore, 

the number of monthly follow-up surveys completed was not consistent across study 

participants. 

To minimize the variation in the number of follow-ups completed per eligible month, two 

steps were taken. First, the follow-up surveys were grouped into five time periods 

according to the amount of time between the participants’ discharge date and the date of 

their follow-up: (1) baseline; (2) 0 to 5 months; (3) 6 to 11 months; (4) 12 to 17 months; 

and (5) 18 or more months. Second, to ensure participants who had varied number of 

follow-ups within each time period were neither under- nor over-represented in the data, 

the follow-ups interviews were weighted such that each participant’s follow-up data 

within a time period was equivalent to one follow-up. For example, if a leaver had three 

follow-ups in a given time period, data from each of their follow-ups would be weighted 

“0.33.” Similarly, data for a leaver with only one follow-up during the same time period 

would be given a weight “1,” and data for a leaver with five follow-ups in would carry an 

equal weight of “0.20” for each follow-up. 

In addition to prospective tracking data from the 96 leavers, we also examined the pattern 

of service use among 385 leavers in the retrospective tracking sample. Service use 

information includes post-permanent housing homeless shelter stays, use of communitybased mental health services, and use of inpatient psychiatric services. 

This section is structured in the following manner: first, we provide an overall profile of 

the post-permanent housing careers of 96 leavers. The profile provides quantitative 

information on the aggregate patterns of current residence and living situation (including 

daytime activities, income support, rent, and subjective quality of life) over the course of 

the study. The quantitative information is then complemented with service use data 

available in the integrated longitudinal data from the retrospective sample of 385 leavers. 

Then we compare the post-permanent housing careers of voluntary and involuntary 

leavers, based on qualitative responses to open-ended questions collected from 96 leavers 

of the prospective tracking sample. This comparison is important given the differences 

between the two groups in their experience after permanent housing. 

46 
Aggregate Profile of the Post-Permanent Housing Careers of Leavers 

Table 4.3 describes the current residence and living situations of the prospective tracking 

sample in five periods over 18 months after permanent housing departure. At the initial 

contact, all 96 leavers completed the baseline interviews. The numbers of leavers that 

completed follow-up interviews are as follows: 53 leavers (55%) at 0-5 months; 60 

leavers (63%) at 6-11 months; 39 leavers (41%) at 12-17 months; and 19 leavers (20%) at 

18 months or more. The number of those who could be tracked for the full 18 months 

after departure was limited not only by the challenge of tracking this hard-to-follow 

population over time but also because of the difficulties of finding them and engaging 

them into the study initially. In the 6 to 11 month period we had an increase in followups conducted because we instituted additional tracking methods to improve our capacity 

to access more participants for the baselines and follow-ups. However, the value of these 

new/modified methods and initiatives tended to diminish over the extended interview 

period as the challenges to maintain contact became more formidable, for example, 

leavers with substantial breaks in contact time. 

TABLE 4.3: POST-PERMANENT HOUSING CAREERS OF LEAVERS— 

CURRENT RESIDENCE & LIVING SITUATIONS 

Variable Category Baseline 

(n= 96) 

Number of months between 

discharge and follow-up interviews 

0-5 

(n=53) 

6-11 

(n=60) 

12-17 

(n=39) 

18+ 

(n=19) 

Type of current 

residence 

Apt./House w/subsidy 

Apt./House w/o subsidy 

Share residence w/family or friends 

Community Residence 

Single Room Occupancy 

Homeless 

Institutions 

Detox/Drug and Alcohol Rehab 

Other Residence 

55% 

2% 

7% 

11% 

2% 

6% 

1% 

6% 

8% 

55% 

11% 

4% 

5% 

4% 

9% 

2% 

3% 

6% 

62% 

7% 

2% 

10% 

6% 

5% 

2% 

2% 

5% 

83% 

0% 

0% 

5% 

3% 

6% 

0% 

3% 

0% 

85% 

4% 

3% 

5% 

4% 

0% 

0% 

0% 

0% 

Employment Received income from employment 21% 23% 23% 18% 24% 

Assessment about 

quality of life 

Delighted/Pleased 

Mixed/Mostly Satisfied 

Terrible/Unhappy/Mostly Dissatisfied 

51% 

39% 

10% 

52% 

39% 

8% 

53% 

37% 

10% 

65% 

26% 

8% 

61% 

30% 

9% 

Mental health service Used a therapist 63% 70% 75% 57% 72% 

Day program Attended a structured day program 37% 44% 37% 39% 34% 

Volunteer work Did volunteer work 26% 26% 26% 33% 26% 

Supplemental 

Security Income 

Received supplemental security income 66% 64% 67% 66% 71% 

Food Stamps Received Food Stamps 21% 24% 27% 40% 44% 

Monthly income Mean monthly income $660 $652 $656 $662 $616 

Monthly rent Mean monthly rental paid $203 $239 $206 $176 $103 

Feelings about 

current residence 

Delighted/Pleased 

Mixed/Mostly Satisfied 

Terrible/Unhappy/Mostly Dissatisfied 

43% 

40% 

17% 

52% 

39% 

8% 

53% 

37% 

10% 

65% 

26% 

8% 

61% 

30% 

9% 

47
 
Notwithstanding the limitation of the tracking data, several observations can be discerned 

from the table. First, it appears that over time a greater proportion of leavers with whom 

contacts had been maintained were living in subsidized housing. This contrasts with the 

declining percentages of leavers who were either homeless, in institutions (prison and 

hospital), or in detoxification or drug and alcohol rehabilitation. Coupled with the more 

favorable living arrangement of permanent housing leavers is the decreasing rent23 

burden borne by the study participants. It is also noteworthy that a greater percentage of 

leavers received Food Stamps over the course of study, and consistently high proportions 

(around two-thirds) received Supplemental Security Income at all five time periods. 

Moreover, the majority of leavers were connected with mental health services by 

reporting to have worked with a therapist after leaving permanent housing. Between 18 

and 24 percent of leavers were employed at the five time periods of the study, between 34 

and 44 percent had attended a structured day program, and between 26 and 33 percent did 

volunteer work during the study period. Overall, leavers of the study were generally 

satisfied with their current residence and had positive assessment of their quality of life. 

The percentages of leavers who expressed dissatisfaction were quite low and did not vary 

across the five time periods. 

 We acknowledge, though, the inherent problem with this analysis in that we are most 

likely to be able to track those who have housing subsidies, those who are most pleased 

with their current situation, and those whose current income most surpasses their rents, 

that is, those who are doing best. 

Table 4.4 provides supplementary information on post-permanent housing service use 

patterns among leavers. The statistical distributions are based on 385 leavers from the 

retrospective sample. Most noticeable in the table is the percentages of leavers who, 

since leaving permanent housing, had registered a stay in a homeless shelter (20%), had a 

Medicaid (City Behavioral Health) inpatient claim (20%), and had an emergency service 

claim in the community rehabilitation service (CRS) system (17%) subsequent to their 

departure from permanent housing. The use of these services is indicative of poorer 

outcomes of a segment of permanent housing leavers. 

23 The question “How Much Rent Do You Pay?” was asked in the baseline and follow-up surveys. The 

average rent declined from $275 (0-2 months after discharge) to $103 (18+ months after discharge). 

48 
TABLE 4.4: POST-PERMANENT HOUSING SERVICE USE PATTERNS OF 

LEAVERS (N = 385) 

Variables 

Leavers 

N (%) 

Mean of 

Users 

Only 

Homeless Shelter Use 

Ever stay in public shelter 59 (15.3) 

Number of public shelter stays 3.4 

Number of days in public shelter 67.9 

Ever stay in public and/or mental health shelter 76 (19.7) 

Medicaid (CBH) Service Use 

Intensive case management (ICM) claims 134 (34.8) 67.87 

Outpatient claims 130 (33.8) 61.35 

Inpatient claims 76 (19.7) 3.87 

Community Rehabilitation Services (CRS) Service Use 

Intensive case management claims 32 (8.3) 5.91 

Outpatient claims 50 (13.0) 3.70 

Day treatment (partial hospital) claims 27 (7.0) 6.59 

Vocational/social rehabilitation 49 (12.7) 4.96 

Community residential services 81 (21.0) 8.06 

Other Case Management services 75 (19.5) 8.16 

Emergency services claim 65 (16.9) 3.23 

Post-Permanent Housing Careers of Voluntary Leavers and Involuntary Leavers 

Interviews with leavers yielded a richer and more dynamic picture of the post-permanent 

housing careers of leavers: 

Voluntary Leavers (Opportunity Seekers)—Over the tracking period, opportunity seekers 

were generally very pleased with their current residence. The positive appraisal of their 

living situation seems to have been related to the level of independence they experienced, 

the peaceful nature of the housing environment, which enabled them to focus, as well as 

the feelings of safety and convenience of the location of their neighborhood. They did 

raise some concerns about bad neighbors and the need of improvement in building 

maintenance. Opportunity seekers also frequently spoke about their plans and goals for 

the future, suggesting a sense of control over their lives. 

Independence 

For opportunity seekers, being free of structure and able to do what they want are highly 

valued. Some used the notion of independence to gauge whether they can manage their 

lives on their own and have control over their own lives. Among some opportunity 

seekers, the desire to become independent alone had motivated them to “graduate” from 

their respective permanent housing program. 

49 
Jennifer M. is a 43 year-old female who departed after two years and nine months in 

permanent housing. In her 2nd month after the baseline interview, she expressed a sense 

of independence: “I haven't changed my feeling since last time. I'm feeling okay, pretty 

comfortable. I like the independence of not being in the program. There's no one to 

dictate to me; I can be my own person now.” 

Maria S. is a 42 year-old female who departed after two months and 12 days in 

permanent housing. The theme of independence resounds in the 1st month after the 

baseline interview. She states that she is on her own and doesn't have to report to anyone. 

Her neighbors are considerate, and she can do what she likes. 

Peaceful/Able to Focus 

Opportunity seekers claimed that their living environment is very important to their 

quality of life. Many described their apartment as a “safe haven” which offered a respite 

from the vagaries and stresses of their daily lives and the encouragement to deal with the 

challenges the next day might hold. 

William D. is a 53 year-old male who departed after one year and 11 months in 

permanent housing. This is what he had to say regarding his home in the 3rd month after 

the baseline interview: "I love it. It's very tranquil, a restful place. It’s my refuge. I don't 

have to answer the phone if I don’t want to. I can just be by myself. It’s becoming more 

and more like a sanctuary.” William also reported he spent much of his time away from 

home, but that, when there, he likes to “tune out.” 

Susan M. is a 40 year-old female who departed after one year and nine months in 

permanent housing. The interviewer’s notes in the 8th month after the baseline interview 

reflected a high level of satisfaction with the environment of her home. Susan stated that 

her home environment is peaceful and quiet. She spends a great deal of time relaxing, 

thinking, watching TV, and talking on the phone. She also eats healthy and exercises in 

the apartment. 

Location & Safety 

Opportunity seekers are interested in living in a neighborhood close to shopping, 

transportation and safe. These conveniences helped make their lives more manageable, 

particularly during stressful times. 

Again, William D. is a 53 year-old male who departed after one year and 11 months in 

permanent housing. In the 1st month after the baseline interview, William liked his 

neighborhood very much and considered it very clean and safe. He also told the 

interviewer that there is a large police presence (many live in the area) in his 

neighborhood, which makes him feel safer. 

Margaret D. is a 42 year-old female who departed after two months and 15 days in 

permanent housing. In the 10th month after the baseline interview, she reported her 

50 
feelings about her new location: "I like it; it's convenient to transportation and stores. 

The neighborhood is quiet.” 

Issues with Neighbors 

Opportunity seekers mentioned problems with neighbors fairly often. Sometimes the 

situations seem to have been exacerbated by their inadequate communication or conflict 

resolution skills. One leaver commented that screening/evaluation at his current 

residence needs to be improved to avoid acceptance of persons not “ready” to live 

independently. 

David R. is a 48 year-old male who departed after one year and five months in permanent 

housing. During the 5th month after the baseline interview, he reported problems with a 

noisy neighbor directly above him. David had spoken to the neighbor about his loud 

television watching, but that has apparently just made the situation worse. Now, 

whenever David plays his stereo, the neighbor comes downstairs and demands that he 

make less noise. David believes that the neighbor is also part of a similar permanent 

housing program. 

Richard C. is a 50 year-old male who departed after three years and seven months in 

permanent housing. In the 2nd month after the baseline interview, he reported that he was 

feuding with his upstairs neighbor. He believes that she spies on him and may be 

bugging his phone – he also admits that he sometimes spies on her as well. According to 

Richard, she had been admitted to the hospital for mental health-related problems but had 

returned to the same apartment. Other than that neighbor, he loves his area but doesn’t 

go out much. 

Building Maintenance 

Where they live is of great value to opportunity seekers. Their residence can lead, 

alternately, to a peaceful or stress-filled life. Problems with building maintenance, 

however, may disrupt the sense of peacefulness that place can engender. 

Dorothy L. is a 42 year-old female who departed after one year and four months in 

permanent housing. In the 4th month after the baseline interview, she remarked that her 

building’s maintenance staff was not fixing deteriorating areas such as the laundry room. 

Lisa N. is a 39 year-old female who departed after three years and six months in 

permanent housing. In the 11th month after the baseline interview, she said the 

maintenance people in her building needed to be more responsive and fix things quickly 

when asked. 

Voluntary Leavers (Situational Leavers)—In general, situational leavers expressed 

satisfaction with their current residence. However, their comments varied more widely 

than those of opportunity seekers, spanning from highly satisfied to dissatisfied. 

51 
Generally Positive Experience with Current Residence 

Charles J. is a 32 year-old male who departed after three years and two months in 

permanent housing. In the 1st month after the baseline interview, he said: "It's okay, nicer 

than where I used to live." When asked what he did not like about where he lived, he 

replied: "I like everything." When queried specifically about maintenance, convenience 

to public transportation, friends, family, and the neighbors, he replied that he liked it all 

just fine. 

Joseph T. is a 58 year-old male who departed after four years and 16 days in permanent 

housing. In the 9th month after the baseline interview, he recounted that he likes his new 

living arrangement. Specifically, he liked the privacy, the laid-back atmosphere and the 

lack of drug problems among fellow tenants. 

Mixed Experiences with Current Residence 

Nancy K. is a 32 year-old female who departed after five years in permanent housing. 

She gave a somewhat mixed account of her current living situation in the 5th month after 

the baseline interview. She reported that her house was satisfactory but believed that her 

neighbors harass both her and her husband. Nancy also believes that the police who live 

in her neighborhood are somehow monitoring her phone calls. 

Betty H. is a 46 year-old female who departed after five years in permanent housing. In 

the 1st month after the baseline interview, the participant expressed that she loves her 

apartment. Betty remarked how much peace of mind she has living in her building; 

however, she did report an incident where someone in the building had stolen a bag of 

canned goods that had been set out for donation to a local food bank. 

Negative Experiences with Current Residence 

Again, Betty H. is a 46 year-old female who departed after five years in permanent 

housing. In the 2nd month after the baseline interview, Betty expressed concern about 

whether some of the newer tenants in her building (who are from programs similar to 

hers) are prepared enough or capable enough to function well on their own. She believes 

some of them in her building are doing drugs or drinking. 

Thomas C. is a 67 year-old male who departed after three years and 10 months in 

permanent housing. In the 2nd month after the baseline interview, Thomas reported that 

he was having difficulty with what he suspected as being illicit drug activity right across 

the hall from his apartment. He also reported that the noise level created by the late-night 

comings and goings of residents had made living in his building demonstrably worse. No 

one in authority, in Thomas’ view, seems to be able to address the situation. 

Involuntary Leavers—Generally, the involuntary leavers’ comments indicated they were 

pleased with their current residence for reasons similar to those expressed by voluntary 

leavers. However, compared to voluntary leavers, involuntary leavers, especially those 

52 
with drug and alcohol problems, tended to report more problems with their environment 

and/or neighbors. 

Positive Experiences with Current Residence 

Helen S. is a 45 year-old female who departed after one year and seven months in 

permanent housing. As revealed in the 2nd month after the baseline interview, she still 

liked her neighborhood and loved her home. She also felt that she had made some real 

progress in her therapy. She had also been frequenting a local center for social events. 

Unfortunately (in her opinion), because of a medical condition that required her to have a 

roommate, Helen was moving to Roxborough, to share an apartment she found through a 

mental health agency. 

Sandra D. is a 27 year-old female who departed after one year and four months in 

permanent housing. In the 1st month after the baseline interview, she felt more 

comfortable in her current situation than at her previous permanent housing program. 

Sandra felt there was more privacy after she left permanent housing —the apartment she 

has now has more space for her and her baby daughter. She liked the idea of having her 

own living room and kitchen. Sandra thought it had been a positive thing to leave the 

previous permanent housing program. 

Christopher D. is a 37 year-old male who departed after two years and three months in 

permanent housing. In the 17th month after the baseline interview, the participant told the 

interviewer that he liked his new residence. Christopher no longer needed to go to the 

soup kitchen, his residence keeps him off the streets, and he can more easily maintain 

personal cleanliness. He considers independent living to be very important. 

Negative Experiences with Current Residence 

Daniel P. is a 36 year-old male who departed after 13 years in permanent housing. In the 

12th month after the baseline interview, the participant thought his residence was 

peaceful, but that there was not enough structure for him. He had slipped up a few times 

and had been drinking. He had come to the conclusion that he might need a program 

with more structure and support. Daniel added that, although he is afraid of the 

neighborhood’s temptations, he nonetheless finds his apartment cozy. 

Donna C. is a 42 year-old female who departed after four years in permanent housing. In 

the 1st month after the baseline interview, she was worried about being evicted due to her 

failure to maintain sobriety. She reports that others in her building are doing drugs and 

this environment makes it even more difficult for her to remain compliant. 

53 
Summary 

The findings presented in this chapter indicate that departure from permanent housing 

programs is a multifaceted event reflecting diverse sets of circumstances faced by persons 

with serious mental illness in their effort to live in the community. For the majority of 

the leavers tracked in the prospective sample, leaving permanent housing is a voluntary 

event involving a decision agreed on between the resident and the permanent housing 

staff. For others, although their leave was voluntary with concurrence from program 

staff, it was to a residential setting that had less independence and more supportive 

services. It appears this leave could be construed as “positive” because it was the 

appropriate residence for the leaver based on their needs and level of functioning. This is 

evidenced by: (1) less than 10% moved from these residences in the study period; and 

(2) almost half (46%) of these leavers were satisfied with their post-permanent housing. 

The findings on the circumstances of leaving and the post-permanent housing careers of 

involuntary leavers clearly differentiate a subgroup of permanent housing residents with a 

lower level of independent living skills and who need more intensive support and 

services from staff by the time they were asked to leave their programs. Involuntary 

leavers, in general, also experienced a less favorable housing experience after leaving 

permanent housing. It is, therefore, important to identify risk factors for this subset of 

residents. In the next chapter, we seek to identify factors that are associated with leaving 

permanent housing in general, and with involuntary leaving in particular. 

54 
CHAPTER 5: FACTORS ASSOCIATED WITH LEAVING PERMANENT 

HOUSING 

Overview 

This chapter examines socio-demographic, service use, and program characteristics 

associated with leaving or staying in permanent housing for persons with serious mental 

illness in Philadelphia. Informed by the findings described in the previous two chapters, 

we identified subgroups of leavers. Based on the discharge codes available in the 

integrated longitudinal database, we categorized leavers into those with a positive discharge 

(positive leavers) and others whose discharge location reflected a less favorable or more 

ambiguous exit from permanent housing (non-positive leavers). From the information 

provided by former permanent housing residents and the permanent housing program staff 

in the interview study, we also divided the sample of 96 leavers into voluntary and 

involuntary leavers. 

For the retrospective tracking sample, characteristics of 558 stayers were compared to 

those of positive leavers (117) and non-positive leavers (247). For the prospective 

tracking sample, characteristics of a matched-sample of 100 stayers were compared to 

those of voluntary leavers (59) and involuntary leavers (37). The contemporaneous 

comparison of leavers and stayers using administrative and interview data has afforded us 

an opportunity to examine a diverse set of potential predictors of residential outcomes of 

permanent housing residents. 

We find notable differences when we compare non-positive leavers to other positive 

leavers and stayers. Despite the fact that the three groups are quite comparable in 

background and characteristics, there are significant differences among the groups in 

their use of services. Non-positive leavers were more likely to need support services and 

more likely to use shelters and inpatient psychiatric services. Clearly, there are “gaps” in 

Permanent Housing’s ability to address the needs of these “at-risk” leavers, and the 

knowledge and understanding of these “gaps” are essential to developing strategies and 

tactics to fill them. 

Categories of Leavers 

Before we proceed further, it is important to clarify the criteria upon which the project 

designated residents who departed from permanent housing into categories of positive or 

non-positive leavers, as well as categories of voluntary or involuntary leavers. Table 5.1 

gives an overview of how permanent housing leavers were categorized in both the 

retrospective and prospective tracking sample. 

55 
TABLE 5.1: CATEGORIZATION OF LEAVERS
 

Study • Retrospective tracking • Prospective tracking 

Data • Integrated longitudinal 

administrative data 

• Interview data 

Information 

source • Disposition codes from OMH database • Leaver descriptions of circumstances 

of leaving 

• Program staff descriptions of the 

circumstances of leaving 

Leaver categories • Positive leaver & non-positive leaver • Voluntary leaver & involuntary leaver 

Leaver subcategories • None • Voluntary leaver (opportunity seeker) 

& voluntary “situational” leaver 

Criteria for 

ascertaining 

leaver categories 

• “Normalized” living arrangement vs. 

“institutionalized” living arrangement 

• Availability of information on 

discharge destinations 

• Agreement between leaver and staff in 

regard to whether leaving is voluntary 

or involuntary; where they differ, staff 

judgment is determining 

• Appropriateness of housing 

arrangement post-permanent housing 

departure 

• Desirability of circumstances of 

leaving 

Definitions of 

categories • Positive leaver 

- Community living arrangement 

- Provision of no residential services 

• Non-positive leaver 

- Provision of more intensive support 

 than permanent housing 

- Institutionalization 

- Homelessness 

- Unspecified or unknown location 

• Voluntary leaver 

- Plans to Leave 

- Finds leaving desirable 

- Has concurrence and support of

 housing and program support staff 

• Involuntary leaver 

- Asked or forced to leave 

- Leaving is the choice of housing 

providers and program staff but not 

permanent housing residents 

Definitions of 

sub-categories • None • Voluntary leaver (opportunity seeker): 

“Graduated” from the program to a 

higher level of independence 

• Voluntary “situational” leaver: 

Deteriorated health or find permanent 

housing too demanding but found 

appropriate housing upon departure 

from permanent housing (mostly 

housing with more intensive support 

than permanent housing) 

56 
The categorization of leavers in the retrospective tracking sample was based on the 

disposition (discharge) code available in the Office of Mental Health (OMH) database. 

There are two criteria for ascertaining if a leaver experienced “positive” or “non-positive” 

leaving: (1) whether the post-permanent housing living arrangement is a normalized 

setting (vs. an “institutionalized” setting); and (2) whether information on the discharge 

destination is available. Based on these two criteria, positive leavers were designated as 

individuals who left permanent housing to an independent living setting or to other 

community living arrangements such as living with spouse/significant other, family 

members and friends. Non-positive leavers were designated as those with discharge 

codes, including congregate residential settings, institutional settings (hospitals and 

correctional institutions), homelessness, and other unspecified or unknown whereabouts. 

While it can be argued that living with friends and family members may not indicate a 

true progression from permanent supportive housing as in the case of independent living 

(without residential support), it is nonetheless a “normalized” living arrangement for the 

general population. Moreover, as the housing preference data shown for this population 

(refer to Table 3.2.B), nearly half of permanent housing residents regarded living with 

family members a preferred housing arrangement. 

The categorization of leavers in the prospective sample was based on both resident and 

staff descriptions of the circumstances of leaving. As noted in the previous chapter, the 

differentiation between voluntary and involuntary leavers was based on three criteria: (1) 

agreement between the leaver and staff whether departure is voluntary or involuntary; (2) 

appropriateness of housing arrangement post-permanent housing departure; and (3) 

desirability of circumstances of leaving. Among voluntary leavers, two subgroups were 

identified: (1) opportunity seekers who progressed to a higher level of independence; and 

(2) voluntary “situational” leavers who found appropriate but more structured, congregate 

housing because of a deteriorating health situation or finding permanent housing too 

demanding. In the analyses reported in this chapter, we combined opportunity seekers 

and voluntary “situational” leavers as voluntary leavers. 

As a result of the differing criteria used, it is possible for a permanent housing leaver to 

be classified as a non-positive leaver in the retrospective sample and a voluntary leaver in 

the prospective tracking sample. An obvious example is a voluntary situational leaver 

who departed permanent housing to a congregate mental health or substance treatment 

program. Whereas the discharge code in the OMH database would designate the 

individual as experiencing non-positive leaving (because of the more “institutionalized” 

nature of the housing setting), both the leaver and program staff interviewed may agree 

that “stepping down” (that is, from an supported independent setting to a congregate 

setting with more intensive and structured care) is both a desirable and appropriate 

arrangement for the resident. As the administrative data provide neither assessment from 

the program staff nor from the leaver, it is not possible for the project to ascertain the 

appropriateness of the housing setting. 

57 
Factors Associated with Leaving and Staying in Permanent Housing—Retrospective 

Tracking Sample 

In this section, we examine factors that may be associated with leaving or staying in 

permanent housing for persons with serious mental illness in Philadelphia using data 

from the retrospective tracking sample. Based on the discharge codes available in the 

longitudinal integrated database, we identified 117 positive leavers and 247 non-positive 

leavers (refer also to Table 3.4 in Chapter 3). Not included in the analysis were 21 prior 

permanent housing residents with “death” as the reason of discharge recorded in the 

integrated database. 

Stayers, positive leavers and non-positive leavers were compared in five different areas. 

These include: (1) demographic and psychiatric diagnostic characteristics; (2) shelter use 

data (including public and mental health shelters); (3) Medicaid (CBH) psychiatric 

service claims data; (4) City Behavioral Health funded (non-CBH) CRS psychiatric 

service claims data; and (5) program-level data from 27 residential support teams offering 

support services for permanent housing residents. 

Socio-Demographic and Diagnostic Characteristics 

Table 5.2 gives a profile of the 922 permanent housing residents and compares the sociodemographic and diagnostic characteristics of stayers, positive leavers, and non-positive 

leavers. As the data show, permanent housing residents were on average 42 years old, 

and females were slightly over-represented. A little more than two-thirds of the 

permanent housing residents were Black/African American, and about three in ten 

residents were white. A very small percentage (3 percent) of permanent housing 

residents reported their ethnicity as “Latino.” As expected, the majority (86 percent) of 

permanent housing residents had a diagnosis of serious mental illness, with a nearly 2:1 

ratio of schizophrenia or related disorder to major affective disorders (including major 

depression and bipolar disorder).24 The average length of stay in permanent housing for 

the 922 residents was 1,329 days, or 3.65 years.25 

24 We define serious mental illness as a primary diagnosis of major mental illness, including schizophrenia 

or major affective disorder (chapter 3, section on persons with serious mental illness). The psychiatric 

diagnostic codes for schizophrenia and major affective disorders are, respectively, 295 and 296. Among the 

943 permanent housing residents, 2% has a missing code on psychiatric diagnosis. Twelve percent has a 

diagnostic code other than 295 or 296. Residents with a record of other codes were mostly diagnosed with 

other psychotic and affective disorders but not with “295” and “296,” which are considered serious mental 

illness. 25 The “length of stay” for leavers was computed by subtracting the discharge date from the admission date. 

The “length of stay” for leavers was computed by subtracting the end date of longitudinal integrated 

database (July 15, 2004) from the admission date. Note that the mean of 3.65 years is inevitably an 

underestimate of the average length of stay because stayers would have a longer tenure in permanent 

housing than what was recorded in the end date of the database (July 15, 2004). 

58 
TABLE 5.2: SOCIO-DEMOGRAPHIC, DIAGNOSTIC, AND FUNCTIONING 

CHARACTERISTICS 

Variables 

Stayers 

(n = 558) 

Positive 

Leavers 

(n =117) 

Non-positive 

Leavers 

(n = 247) 

All 

Residents 

(N = 922) 

Age at admission to permanent housing (mean)

# 42.83 41.10 41.52 42.26 

Gender 

- Females 53.0% 51.3% 51.8% 52.5% 

- Males 47.0% 48.7% 48.2% 48.2% 

Race 

- White 31.0% 30.0% 26.0% 29.5% 

- Black 67.9% 68.2% 72.3% 69.1% 

- Other 1.1% 1.8% 1.7% 1.4% 

Latino 2.5% 2.3% 4.3% 2.9% 

Serious mental illness 86.2% 81.2% 88.3% 86.1% 

- Schizophrenia 55.2% 52.1% 58.3% 55.6% 

- Affective disorders 31.0% 29.1% 30.0% 30.5% 

Number of days in permanent housing 

(mean)*** 

1542.97 1034.64 984.83 1328.94 

Note: 
 

Statistical significance: # p < .10. * p < .05. ** p < .01. *** p < .001. 
 

Comparing stayers, positive leavers and non-positive leavers indicates no statistically 
 

significant differences between the three groups in terms of gender, race/ethnicity, and 
 

psychiatric diagnoses. Stayers were slightly older than positive and non-positive leavers. 
 

Although it is obvious that stayers had a significantly longer tenure in permanent housing 
 

than leavers, it is important to note that both positive leavers and non-positive leavers 
 

reported a relatively long stay in permanent housing. Interestingly, there is a relatively 
 

small difference in the average length of stay between positive and non-positive leavers 
 

(50 days). 
 

Stay History in Homeless Shelter 

Table 5.3 shows the distribution of homeless shelter stays for three distinct time periods: 

(1) prior to permanent housing entry; (2) during permanent housing stay; and (3) post 

permanent housing exit (for positive and non-positive leavers only). The table is divided 

into three panels according to the type of shelter: ever stayed in public shelter (tracked in 

the administrative database of Office of Emergency Shelter Services {OESS}); ever 

stayed in mental health shelters ((including short-term shelters, long-term shelters, and 

59
 
progressive demand residences (PDR) targeted for homeless mentally ill persons operated 

by the mental health system)); and total stays in either public or mental health shelters.26 

TABLE 5.3: STAY HISTORY IN HOMELESS SHELTER 

Variables 

Stayers 

(n = 558) 

Positive 

Leavers 

(n =117) 

Non-positive 

Leavers 

(n = 247) 

All 

Residents 

(N = 922) 

Ever stayed in Public Shelter 

- Prior to permanent housing Entry* 37.5% 47.9% 46.2% 41.1% 

- During permanent housing stay** 1.6% 3.4% 6.1% 3.0% 

- Post permanent housing exit* N.A. 10.3% 19.0% N.A. 

Ever stayed in Mental Health Shelter 

- Prior to permanent housing Entry* 15.9% 19.7% 24.3% 18.7% 

- During permanent housing stay*** 6.6% 12.8% 17.4% 10.3% 

- Post permanent housing exit*** N.A. 1.7% 13.4% N.A. 

Ever stayed in Public or Mental Health Shelter 

Combined 

- Prior to permanent housing Entry* 43.9% 52.1% 54.3% 47.7% 

- During permanent housing stay*** 8.2% 16.2% 22.3% 13.0% 

- Post permanent housing exit** N.A. 10.3% 25.9% N.A. 

Note: 

Statistical significance: # p < .10. * p < .05. ** p < .01. *** p < .001. 

As the data shows, stayers were significantly less likely than leavers to have a shelter stay 

in both public and mental health shelters before entering permanent housing as well as 

during permanent housing stay. The percent of stayers who ever had a shelter stay also 

declines substantially from the period prior to entering permanent housing to that during 

the permanent housing stay, with stay in public shelter declining from 38% prior to 

entering permanent housing to less than 2% during permanent housing stay, and stay in 

mental health shelter declining from 16% to 7% during the same period.27 An interesting 

point to note from the data table is that, while not prevalent, it is not exactly a rare event 

for permanent housing residents to experience a stay in a mental health shelter or PDR 

during their stay in permanent housing (10% of all 943 residents experiencing at least one 

stay; 13% and 17%, respectively, for positive and non-positive leavers). The 

phenomenon of staying in a PDR or mental health shelter may signal the need for more 

intensive support for permanent housing residents, or the presence of housing and 

26 Shelters are emergency facilities that are designated for the use of the homeless mentally ill population in 

the city. PDR is a transitional, congregate community-living arrangement, which is targeted to mental 

health consumers who, in addition to having a serious mental illness, are homeless. Admissions to shortterm shelters, long-term shelters, and PDR are administered by the Access to Alternative Services Unit 

(AAS), a single point of entry for homeless persons with serious mental illness. 

27 Because permanent housing stayers have a longer average length of stay (refer to Table 5.2), the 

exposure time to ever staying in mental health shelters and PDR during permanent housing tenure is 

inevitably longer. The significantly lower percentage of stayers who ever used mental health shelters and 

PDR making the differences between stayers and leavers in utilization rate even more distinctive given 

stayers’ longer exposure time. 

60
 
neighborhood issues that need to be addressed in order to for the permanent housing 

resident to maintain permanent housing. 

The data reveal a slight difference in shelter use (both public and mental health shelters) 

between positive and non-positive leavers. However, when compared to non-positive 

leavers, positive leavers experienced a larger reduction in shelter use rates during their 

stay in permanent housing. More importantly, non-positive leavers are more than two 

times as likely than positive leavers to have ever used public or mental shelter after 

departing from permanent housing (26% for non-positive leavers and 10% for positive 

leavers). 

Service Use Characteristics—Medicaid (CBH) 

Table 5.4 compares the service use characteristics of stayers, positive leavers, and nonpositive leavers using the CBH (Medicaid behavioral health component) claims records 

from 1999 to 2003. Three different types of service claims were examined—intensive 

case management (ICM) services, outpatient services, and inpatient services.28 We 

compare the percentages of permanent housing residents who had at least one service 

claim record prior to entering permanent housing and during permanent housing stay, and 

for leavers, the percentages that had at least one service claim record after they left 

permanent housing. 

As the findings show, proportionately more stayers than leavers reported at least one 

service claim for ICM and outpatient services prior to permanent housing entry, as well 

as during permanent housing stay. However, only the differences in outpatient service 

use between leavers and stayers are statistically significant (p = 0.10). Moreover, among 

leavers, positive leavers were less likely than non-positive leavers to make any claims on 

ICM and outpatient services, including the post-permanent housing period. 

28 Inpatient services refer to hospitalization episodes of permanent housing residents in the psychiatric 

units. 

61 
TABLE 5.4: SERVICE USE CHARACTERISTICS (MEDICAID—CBH) 
 

Variables 

Stayers 

(n = 558) 

Positive 

Leavers 

(n =117) 

Non-positive 

Leavers 

(n = 247) 

All 

Residents 

(N = 922) 

Intensive Case Management (ICM) Claims 

- Prior to permanent housing Entry 32.8% 23.1% 30.8% 31.0% 

- During permanent housing stay 43.7% 35.9% 42.1% 42.3% 

- Post permanent housing exit** N.A. 24.8% 40.9% N.A. 

Outpatient Claims 

- Prior to permanent housing Entry# 47.1% 37.6% 40.5% 44.1% 

- During permanent housing stay# 60.4% 51.3% 53.8% 57.5% 

- Post permanent housing exit* N.A. 26.5% 40.1% N.A. 

Inpatient Psychiatric Service Claims 

- Prior to permanent housing Entry 19.5% 17.1% 19.8% 19.3% 

- During permanent housing stay*** 12.2% 12.8% 28.3% 16.6% 

- Post permanent housing exit# N.A. 15.4% 23.5% N.A. 

Note: 

Statistical significance: # p < .10. * p < .05. ** p < .01. *** p < .001. 

Interestingly, a different pattern of service use emerges for psychiatric hospitalization. 

As panel 3 of Table 5.4 shows, there is no difference in the percentages of stayers, 

positive, and non-positive leavers who ever used inpatient services prior to their entry to 

permanent housing. However, during their stay in permanent housing, non-positive 

leavers (28%) were twice as likely as positive leavers (13%) or stayers (12%) to have an 

inpatient admission, a difference that is statistically significant (p < 0.001). It is also 

worth noting that, while there is a substantial reduction of inpatient service use after 

entering permanent housing for both stayers (from 20% to 12%) and positive leavers 

(from 17% to 13%), the trend is reversed for non-positive leavers. The percentage of 

non-positive leavers who had an inpatient service claim rose from 19% prior to 

permanent housing entry to 28% during permanent housing stay. 

Service Use Characteristics—Community Reporting System (CRS) 

Table 5.5 compares the service use characteristics of leavers and stayers using the 

Community Reporting System (CRS) claims records from 1999 to 2003. Services filed 

under CRS claims are community-based rehabilitation services funded by the Office of 

Behavioral Health Services from state, federal and city sources other than Medicaid. The 

CRS data base has two types of service claims, namely, ICM and outpatient claims, that 

are also funded by CBH through Medicaid. For these services, the data in Table 5.5 

represent only claims that are not found in the CBH claims data in order to avoid double 

counting. 

62
 
TABLE 5.5: SERVICE USE CHARACTERISTICS (COMMUNITY 

REHABILITATION SERVICES—CRS) 

Variables 

Stayers 

(n = 558) 

Positive 

Leavers 

(n =117) 

Non-positive 

Leavers 

(n = 247) 

All 

Residents 

(N = 922) 

Intensive Case Management Claims

a 

- Prior to permanent housing Entry 20.3% 22.2% 24.7% 21.7% 

- During permanent housing stay 14.7% 20.5% 19.0% 16.6% 

- Post permanent housing exit N.A. 6.0% 10.1% N.A. 

Outpatient Claims

a 

- Prior to permanent housing Entry 36.6% 41.0% 37.2% 37.3% 

- During permanent housing stay 30.5% 35.9% 32.4% 31.7% 

- Post permanent housing exit N.A. 12.8% 13.8% N.A. 

Day Treatment (Partial Hospital) Claims 

- Prior to permanent housing Entry 28.5% 22.2% 26.3% 27.1% 

- During permanent housing stay 19.7% 13.7% 23.1% 19.8% 

- Post permanent housing exit N.A. 6.0% 8.1% N.A. 

Vocational/Social Rehabilitation 

- Prior to permanent housing Entry 27.4% 29.9% 26.3% 27.4% 

- During permanent housing stay 37.3% 35.0% 37.7% 37.1% 

- Post permanent housing exit N.A. 9.4% 15.4% N.A. 

Community Residential Services 

- Prior to permanent housing Entry 45.9% 45.3% 44.9% 45.6% 

- During permanent housing stay*** 69.0% 85.5% 81.8% 74.5% 

- Post permanent housing exit*** N.A. 7.7% 29.1% N.A. 

Other Case Management Servicesb 

- Prior to permanent housing Entry 40.3% 39.3% 40.9% 40.3% 

- During permanent housing stay 43.2% 49.6% 46.2% 44.8% 

- Post permanent housing exit N.A. 15.4% 22.3% N.A. 

Emergency Services Claim 

- Prior to permanent housing Entry 33.9% 30.8% 35.2% 33.8% 

- During permanent housing stay*** 19.0% 25.6% 38.9% 25.2% 

- Post permanent housing exit** N.A. 9.4% 21.9% N.A. 

Note: a Only includes Intensive Case Management and Outpatient claims not recorded in 

CBH records. 

b

 Includes resource coordination (a less intensive type of case management compared 

to ICM), administrative management, and housing support claims. 

Statistical significance: # 

p < .10. * p < .05. ** p < .01. *** p < .001; significance 
 

indicator in parentheses refer to mean differences to number of claims among service 
 

users. 
 

63
 
Nearly all (97%) of the 922 permanent housing residents had at least one service claim in 

the CRS records from 1999 and 2003. The proportions of permanent housing residents 

that had a claim vary by types of service and time periods. For example, while only one 

in six of all permanent housing residents had an ICM (funded by CRS) service claim 

during their stay in permanent housing (lowest proportion of use), about three-quarters 

had a community residential service claim during the same time period (highest 

proportion of use). 

Among the seven types of services included in the CRS database, only two types— 

community residential and emergency services—reveal significant differences between 

leavers and stayers in the proportion of service use. Specifically, leavers as a group were 

more likely than stayers to use both community residential and emergency services 

during their stay in permanent housing (p < 0.001 for both types of services). Among 

members of the leaver group, positive leavers were more likely than non-positive leavers 

to use community residential services during their permanent housing stay, but less likely 

to use emergency services. 

Comparing the post-permanent housing and during-permanent housing stay services use 

data for leavers reveals a substantial drop in CRS services use subsequent to leavers’ 

departure from permanent housing. Of particular note is the percentage of leavers who 

had a CRS claim on community residential services. As the data show, about one in 13 

positive leavers and three out of 10 non-positive leavers were connected with residential 

services, down from 86% and 82%, respectively, during positive leavers’ and nonpositive leavers’ stay in permanent housing. The higher proportion of non-positive 

leavers than positive leavers who reported to use community residential services after 

departing from permanent housing is expected, given that 25% of non-positive leavers 

(61 out of 247, refer to Table 3.4) were placed in a mental health community 

rehabilitation program after they left permanent housing. 

Another noteworthy finding is the difference in emergency services use between positive 

and non-positive leavers subsequent to their discharge from permanent housing. About 

one in five (22%) of non-positive leavers had at least one emergency service claim after 

they left permanent housing; only one in ten (9%) of positive leavers used such service 

during the time period. The lower rate of emergency services use among positive leavers 

is suggestive of the relative “health” of these leavers (that is, when compared with nonpositive leavers). Alternatively, it could be the result of the differing housing situations 

in which the two groups of leavers find themselves after departing from permanent 

housing. 

Program Characteristics 

Table 5.6 compares the characteristics of the permanent housing programs offering 

support services for leavers and stayers. Recall that the information was based on a 

survey of 27 permanent housing residential support teams conducted from 2002 to 2003. 

The variables include program size (capacity), extent of independence (decision-making), 

64 
average level of functioning among program participants (Global Assessment of 

Functioning Score)29, and intensity of support (consumer staff ratio, frequency of contact, 

and number of services). As the findings show, there is no statistically significant 

difference between leavers and stayers in any of the above listed variables. Apparently, 

these program-level attributes are not associated with leaving and staying in permanent 

housing. 

TABLE 5.6: PROGRAM CHARACTERISTICS 

Stayers 

Positive 

Leavers 

Non-positive 

Leavers 

All 

Residents 

Variables (n = 558) (n =117) (n = 247) (N = 922) 

Capacity (3 – 72) 38.65 37.46 36.77 38.00 

Decision making (1.2 – 3.2; lower score– 

less staff control) 

2.12 2.09 2.08 2.11 

Global Assessment of Functioning Score 

(mean of residents in permanent housing 

program) 

48.82 48.82 49.22 48.93 

Consumer staff ratio (1.05 – 13.33) 6.13 6.60 6.20 6.21 

Frequency of contact with staff (3 – 5.25) 4.05 3.98 4.09 4.05 

Number of services available (3.5 – 16) 8.89 8.77 8.90 8.88 

Note: 

Statistical significance: # p < .10. * p < .05. ** p < .01. *** p < .001. 

Identification of Predictors of Leaving and Staying Using Multivariate Analysis 

The goal of multivariate analysis is to test the statistical significance of potential 

predictors, including socio-demographic and service characteristics that may affect 

leaving or staying in permanent housing when other variables are controlled for in the 

model. The selection of predictor variables was informed by the descriptive analysis 

results comparing stayers, positive leavers, and non-positive leavers as laid out in 

previous sections. 

Multinomial Logistic Regression was used because we were able to classify permanent 

housing residents into three distinct outcomes as indicated in the discharge codes: (1) 

staying in permanent housing; (2) positive leaving; and (3) non-positive leaving. By 

performing Multinomial Logistic Regression, we can determine the strength of influence 

the selected sets of predictor variables has upon these distinct categories. 

The dependent variable was coded as a three-category variable with stayers assigned a 

value of “1,” positive leavers assigned a value of “2,” and non-positive leavers assigned a 

value of “3.” Stayers were designated as the reference category with which positive 

leavers and non-positive leavers were compared. 

29 The Global Assessment of Functioning (GAF) score of 49 points can be interpreted as having serious 

psychiatric symptoms or any serious impairment of social, occupational, or school functioning. 

65 
Three sets of predictor variables are included in the regression model. The first set is 

composed of demographic characteristics including age, race/ethnicity, gender, and 

length of stay in permanent housing. Age was measured as age of residents at the time of 

their admission to permanent housing, gender was coded “1” for male and “0” for female, 

race/ethnicity was coded “1” for African American/black and “0” otherwise, and length 

of stay in permanent housing was measured by the number of days in permanent housing. 

Demographic variables served as predictor variables as well as statistical controls in 

identifying the net effects of service use variables. For example, length of stay in 

permanent housing is an important control variable because the probability of using 

services during permanent housing stay increases the longer a resident stays in permanent 

housing with all else being equal. All four demographic variables were included 

regardless of the level of statistical significance in the bivariate analysis. 

The second set of predictor variables focuses on service characteristics of permanent 

housing residents prior to their entry into permanent housing. Only two service use 

variables were included based on the presence of a statistical significant relationship with 

stayer-leaver status (cutoff at p < 0.10). Pre-permanent housing homeless shelter use 

(public or mental health shelters) and pre-permanent housing outpatient service use were 

both coded as a binary variable with “1” indicating ever used services and “0” indicating 

otherwise. 

The third set of predictor variables captures service use characteristics of permanent 

housing residents during their stay in permanent housing. Five variables were selected, 

again, based on the presence of a statistically significant relationship (cutoff at p < 0.10) 

between these variables and stayer-leaver status in the descriptive analysis. The five 

variables included shelter use in either the public or mental health shelter system; two 

service variables derived from the CBH database—outpatient and inpatient services; and 

two variables derived from the CRS database—community rehabilitation and emergency 

services. All five variables were coded as a binary variable with “1” indicating ever used 

service and “0” indicating otherwise. We did not include any permanent housing 

program level variables because of the lack of statistically significant association between 

these variables and stayer-leaver status in the descriptive analysis. 

Table 5.7 shows the multinomial logistic regression results of the prediction model. The 

first two columns display results predicting the probability of positive leaving (versus 

staying in permanent housing), while the last two columns display results predicting the 

probability of non-positive leaving (versus staying in permanent housing). We report the 

results using the odds ratio. Simply put, the odds ratio is a way of comparing whether the 

probability of a certain event, in this case, positive (or non-positive) leaving versus 

staying in permanent housing, is the same for categories of a variable. For a variable 

with two categories, an odds ratio of one implies that the event is equally likely in both 

categories of the variable. An odds ratio greater than one implies that the event is more 

likely in the first category (that is, the category coded “1”). An odds ratio less than one 

implies that the event is less likely in the first category. 

66 
TABLE 5.7: MULTINOMIAL LOGISTIC REGRESSION RESULTS 

PREDICTING POSITIVE LEAVING, NON-POSITIVE LEAVING, AND 

STAYING IN PERMANENT HOUSING 

Variables 

Positive Leaving 

Versus Staying in 

permanent housing 

Odds 

Ratio p-value 

Non-positive Leaving 

Versus Staying in 

permanent housing 

Odds 

Ratio p-value 

Demographics & control 

Age at the time of admission 0.968 0.006 ** 0.977 0.013 * 

Gender (male=1) 1.009 0.967 1.055 0.759 

Race/ethnicity (black=1) 0.979 0.927 1.196 0.345 

Length of stay in permanent housing 0.999 0.000 *** 0.999 0.000 *** 

Prior to permanent housing entry 

Ever have a homeless shelter stay 1.223 0.404 1.030 0.877 

Ever used CBH outpatient services 0.214 0.000 *** 0.235 0.000 *** 

During permanent housing stay 

Ever have a homeless shelter stay 1.395 0.328 2.135 0.005 ** 

Ever used CBH outpatient services 1.344 0.314 1.092 0.707 

Ever used CBH inpatient services 1.145 0.708 2.869 0.000 *** 

Ever used CRS community residential services 4.454 0.000 *** 2.778 0.000 *** 

Ever used CRS emergency services 1.415 0.218 2.190 0.000 *** 

Note: 
 

Statistical significance: # p < .10. * p < .05. ** p < .01. *** p < .001. 
 

Two socio-demographic variables—age at admission to permanent housing and length of 
 

stay in permanent housing—have a statistically significant relationship with 
 

leaving/staying. The odds ratio associated with age was 0.968 for positive leaving and 
 

0.977 for non-positive leaving, indicating that older permanent housing residents were 

less likely to experience positive and non-positive leaving than younger residents. 

Therefore, age appears to be a protective factor against the risk of both positive and nonpositive leaving. Albeit statistically significant, it should be noted that the length of stay 

in permanent housing variable does not have any substantive meaning, as it is stating the 

obvious that stayers have longer permanent housing tenure than leavers. The “length of 

stay in permanent housing” variable was included to control the probability of service use 

because of varying length of stay in permanent housing. 

Interestingly, although both positive and non-positive leavers were more likely than 

stayers to report a homeless shelter stay prior to entering permanent housing (recall Table 

5.3), the coefficient of pre-permanent housing shelter stay becomes non-significant when 

67
 
other predictor variables were included in the model for both groups of leavers. In 

contrast, pre-permanent housing use of outpatient services funded by CBH was 

significantly associated with leaving permanent housing. As the results show, permanent 

housing residents who had never used CBH-funded outpatient services before entering 

permanent housing were more likely to leave permanent housing, regardless of whether it 

was positive or non-positive leaving. 

As noted in columns 1-2 of Table 5.7, use of community residential services was the only 

variable associated with positive leaving during residents’ tenure in permanent housing. 

The odds ratio associated with use of community residential services was 4.45, indicating 

that permanent housing residents who used community residential services were 4.45 

times more likely to experience positive leaving (versus staying) than residents who did 

not use such service. 

In contrast, four out of five during-permanent housing service use factors were associated 

with leaving with non-positive outcomes. Permanent housing residents who had a 

homeless shelter stay were 2.14 times more likely to experience non-positive leaving than 

those who had never used shelter during their stay in permanent housing. Service users 

of CBH inpatient services, CRS community residential services, and CRS emergency 

services were more likely to experience non-positive leaving than residents who did not 

use service (with odds ratios of 2.87 for inpatient services, 2.78 for community residential 

services, and 2.19 for emergency services). 

To summarize the multivariate regression results, we list the service factors that are 

significantly associated with positive and non-positive leaving from permanent housing. 

Factors that are associated with positive leaving are: (1) never used CBH outpatient 

services prior to permanent housing entry; and (2) ever used CRS community residential 

services during permanent housing stay. Factors that are associated with non-positive 

leaving are: (1) never used CBH outpatient services prior to permanent housing entry; (2) 

ever had a homeless shelter stay during permanent housing stay; (3) ever used CBH 

inpatient services during permanent housing stay; (4) ever used CRS community 

residential services during permanent housing stay; and (5) ever used CRS emergency 

services. 

Factors Associated with Leaving and Staying in Permanent Housing—Prospective 

Tracking Sample 

In this section, we compare the characteristics of leavers and stayers of permanent 

housing using in-person survey data. The findings were based on 100 stayers and 96 

leavers recruited into the interview study. We begin by examining the basic sociodemographic characteristics between leavers and stayers. This comparison is important 

to ensure that the leaver and stayer samples are matched as originally planned in the 

study. The comparison of socio-demographic characteristics is followed by findings on 

other individual characteristics including behavioral health characteristics, type of 

residence, income sources, and rent-income ratio. The last data table in this section 

68 
presents data on level of functioning and extent of services and support, both reported by 

residential support staff. With the exception of basic socio-demographics, all data tables 

compare voluntary leavers, involuntary leavers, and stayers. Recall that 59 (61%) of the 

leavers were categorized as voluntary leavers and 37 (39%) were categorized as 

involuntary leavers. 

Comparison of Socio-Demographic Characteristics between Leavers and Stayers 

Table 5.8 indicates that the leaver and stayer samples do not differ on the basis of age, 

gender, and race. The lack of differences in basic socio-demographic characteristics 

confirms that the matched-sample design was implemented effectively. 

TABLE 5.8: SOCIO-DEMOGRAPHIC CHARACTERISTICS MATCHED IN 

THE STUDY DESIGN 

Variables 

All Leavers 

(N = 96) 

All Stayers 

(N =100) 

Age 

- 18-44 45% 45% 

- 45+ 55% 55% 

Gender 

- Females 59% 61% 

- Males 41% 39% 

Race 

- White 27% 21% 

- Black 66% 69% 

- Other 6% 10% 

In addition, a detailed analysis of the characteristics of the final leaver and stayer samples 

were compared, respectively, to the characteristics of leavers and stayers who declined 

the interviews or who could not be contacted. There were no significant differences 

between stayers who were interviewed and stayers who declined in terms of age, race, or 

gender. For leavers, there was no difference in race or gender but a statistical significant 

difference (p <.05) in age between those who were interviewed and those that declined 

participation in the study. It appears that the interviewed samples of leavers and stayers 

are comparable and representative of the total cohort of leavers and stayers. 

Comparison of Other Individual Characteristics between Voluntary Leavers, 

Involuntary Leavers, and Stayers 

Table 5.9 compares other individual characteristics, including behavioral health 

characteristics, types of residence, income sources, and rent-income ratio. Comparing all 

leavers with all stayers suggest no difference between the two groups in psychiatric 

diagnosis of schizophrenia. Leavers, however, were more likely to have a diagnosis of 

bipolar disorder and substance abuse problems. A breakdown of leavers into voluntary 

69 
leavers and involuntary leavers suggest an interesting pattern. Considering the 

prevalence of psychiatric diagnosis, it is worth noting that voluntary leavers were the 

least likely of the three groups to be diagnosed with schizophrenia, and involuntary 

leavers were the most likely. The reverse is true for psychiatric diagnosis of bipolar 

disorder, with more than a third of voluntary leavers diagnosed with the disorder, and 

only 10 percent of the involuntary leavers. Interestingly, the prevalence of substance 

abuse problem is similar for voluntary leavers and stayers, but substantially higher for 

involuntary leavers. 

TABLE 5.9: OTHER INDIVIDUAL CHARACTERISTICS 

Variables 

Voluntary 

Leavers 

(n = 59) 

Involuntary 

Leavers 

(n = 37) 

All 

Leavers 

(n = 96) 

All 

Stayers 

(n =100) 

Psychiatric diagnosis of schizophrenia 34% 67% 47% 47% 

Psychiatric diagnosis of bipolar disorder 36% 10% 26% 20% 

Substance abuse problem 15% 47% 27% 13% 

Type of current residence—living in an 

apartment alone 

53% 11% 36% 76% 

Receipt of Food Stamps 17% 27% 21% 34% 

Monthly rent (mean) $175 $247 $203 $150 

Rent-to-income ratio (mean) 0.26 0.43 0.32 0.21 

By virtue of maintaining their tenure in permanent housing programs, stayers were more 

likely than leavers to be living in an apartment alone. Nevertheless, more than half of 

voluntary leavers (53%) were living in an apartment alone at the baseline interview, 

compared with only one in ten involuntary leavers. Aside from living arrangements, 

stayers appear to be in a more favorable situation than leavers by being more likely to be 

receiving Food Stamps, by spending less on rent, and by reporting a lower rent-to-income 

ratio. Interestingly, voluntary leavers reported a lighter rent burden than involuntary 

leavers, although voluntary leavers were less likely than involuntary leavers to receive 

Food Stamps benefits. 

Level of Skills in Independent Living and Extent of Support and Services 

As the data in Table 5.10 show, residential support staff rated voluntary leavers to have 

an equally high (in the areas of transportation, medication management, and self-care and 

self-preservation) or even higher (in the areas of food management, money management, 

and independence) level of skills in independent living than stayers. Involuntary leavers 

were consistently reported by support staff to have a substantially lower level of skills 

than voluntary leavers and stayers. 

70
 
TABLE 5.10: LEVEL OF FUNCTIONING AND EXTENT OF SUPPORT AND 

SERVICES 

Variables 

Voluntary 

Leavers 

(n = 59) 

Involuntary 

Leavers 

(n = 37) 

All 

Leavers 

(n = 96) 

All 

Stayers 

( n = 100) 

Level of functioning (% indicating higher level 

of functioning) 

- Transportation 88% 63% 78% 89% 

- Medication management 88% 37% 68% 84% 

- Self-care and self-preservation 84% 43% 71% 83% 

- Food management 85% 23% 61% 75% 

- Money management 81% 23% 59% 71% 

- Independence 77% 23% 56% 71% 

Extent of support (% indicating less need for 

assistance) 

- Employability/employment skills 50% 31% 43% 36% 

- Dealing with landlord, housing manager, 

neighbors 

40% 23% 33% 33% 

- Transportation 77% 37% 62% 47% 

- Making appointments for medical & 

psychiatric care 

60% 30% 49% 45% 

- Development of natural support networks 67% 33% 54% 36% 

Apparently, the higher level of skills in independent living among voluntary leavers is 

translated into lower level of need for assistance provided by residential support staff. 

Strikingly, in the areas of employment, dealing with landlord and neighbors, 

transportation, making appointments for medical and psychiatric care, and development 

of natural support networks, a higher percent of voluntary leavers were evaluated as 

needing less assistance than either stayers or involuntary leavers. 

Summary 

The key finding of this chapter is that leavers who exited permanent housing 

involuntarily or to less favorable or uncertain discharge locations (non-positive) stood out 

as a group apart from stayers and other leavers (voluntary leavers or positive leavers). 

Based on the reports of residential support staff, involuntary leavers were more likely to 

be diagnosed with a more severe form of mental illness (that is, schizophrenia), had a 

substance abuse problem, demonstrated a lower level of functioning, and were in a higher 

level of need for assistance provided by residential support staff. In regard to services 

used, non-positive leavers were more likely to use inpatient and emergency psychiatric 

services, suggesting the possibility that these leavers had experienced a downward turn of 

their mental illness during their stay in permanent housing. Non-positive leavers were 

71
 
also more likely to experience residential instability during their stay in permanent 

housing, as indicated by the higher shelter use rate. 

These results illustrate the feasibility of identifying permanent housing residents who are 

at risk of unfavorable leaving, especially in the context of a well-integrated service 

system. In the next chapter, we discuss the policy and practice implications to address 

these risk factors in an endeavor to improve the effectiveness of permanent housing 

programs. 

72 
CHAPTER 6: SUMMARY, IMPLICATIONS AND RECOMMENDATIONS 

Overview 

This chapter briefly summarizes the major findings of this study and how they respond to 

the research questions it was intended to address. It also delineates the implications and 

recommendations of the study. The research effort was designed to help understand 

whether and to what degree permanent supportive housing meets the needs of homeless 

people with serious mental illness and especially that population’s need for stable 

housing. The research focused on a particular aspect of this question as it relates to 

determining whether permanent housing is indeed long-term and stable for its residents, 

and whether limited tenure in Permanent Housing results in negative outcomes. To this 

end, this project examined the phenomenon of departure from permanent housing by 

addressing three topical areas. Under each of the three areas, associated research 

questions were identified that would assist the Department of Housing & Urban 

Development, other policymakers and service providers design, administer and/or operate 

permanent housing programs that promote residential stability and self sufficiency. The 

following the three topical areas and the associated research questions. 

•	 Characteristics of permanent housing. What are the distinctive 

characteristics of permanent housing programs? Is permanent housing a 

form of housing that permits long-term residency but in practice is used 

by homeless people with serious mental illness as transitional housing? 

•	 Circumstances of leaving and the post-permanent housing careers of 

leavers. What happens to the formerly homeless people with disabilities 

who leave permanent housing and why do they leave? What do leavers’ 

post-permanent housing residential careers look like over time? Do 

people who leave permanent housing voluntarily have different 

residential careers after permanent housing than those who leave 

involuntarily? 

•	 Factors associated with leaving permanent housing and postpermanent careers. What factors, including the degree and nature of 

disability and the length of time without housing at the time of program 

entry, affect the prospect of leaving or staying in permanent housing? 

What factors, including the degree and nature of disability and the length 

of time without housing at the time participants enter permanent housing, 

affect where leavers go upon departure from permanent housing? 

73 
Summary Findings 

Characteristics of Permanent Housing 

The “support” element inherent in Permanent Housing is a significant distinguishing 

characteristic of Permanent Housing. The support ranges from psychiatric services to life 

skills to sustain the independence of its residents. Although, the intensity and breadth of 

the services may vary program to program it was distinguished as a significant element in 

helping residents attain and maintain their Permanent Housing residency. 

Leaving Permanent Housing cannot be presumed to be an undesirable outcome. In 

actuality, it can be a very positive outcome as leavers move to residences that require 

greater independent living skills and are able to sustain their residential stability. These 

leavers (opportunity seekers) believe leaving Permanent Housing exemplifies how “much 

more” independent they have become. For many it is very gratifying that they can live 

independently outside of the Permanent Housing program. 

Permanent Housing is working effectively for many. It enables residents to aspire to 

integrate into the community at large even more so than may have been initially thought 

possible. Half of the stayers aspire to leave permanent housing to live with family and 

friends. However, they have not left “yet” because they do not believe they are “ready”, 

ready in the sense that they think they will be able to maintain a post-permanent housing 

residence. Permanent housing enables them to move when and if they choose. Yet, they 

are prepared to remain in permanent housing if they do not achieve the “ready” state. For 

example, half of the leavers resided in permanent housing for over two years before 

leaving. 

“Successful leavers” from permanent housing have in some sense demonstrated they can 

manage their disabilities and sustain a residence outside of permanent housing. In 

contrast, at least some leavers with less successful outcomes appear to need greater 

assistance than generally provided in permanent supportive housing. Those who departed 

to residences with greater support may at some point return to permanent housing. On 

the other hand, those who are institutionalized or return to the street may not be able to 

return. For those who fall into either disposition it will be helpful to be able to identify 

them before departure, to intervene and avoid, if possible, an unfavorable departure. 

So is permanent supportive housing for all intents and purposes simply a form of 

transitional housing? Overall, the answer is “no” but with exceptions. For many it is 

permanent housing in the same sense that housing is permanent for non-homeless people. 

People may not stay there forever, but it has become their long-term address, where they 

come “home” most nights. For others, who are perhaps better functioning and have 

achieved some real stability in their mental illness, graduation from supportive housing to 

housing with a subsidy but less structure is a genuine possibility. For others, permanent 

supportive housing is the place where they’ll still take you in after episodes in mental 

hospitals or substance abuse facilities or on the streets or in shelter. For still others, its is 

74 
just one more place with rules and requirements, and, despite the promise, the client just 

cannot abide that or the provider cannot abide the client. 

Circumstances of Leaving 

Leavers most often leave to seek better housing. These leavers tend to be voluntary 

leavers (“opportunity seekers”) who are highly motivated to seek a residential setting 

they perceive to be an improvement over Permanent Housing. Once they “elect” to leave 

and they generally are able to sustain a stable post-permanent housing residential career. 

This “graduation” is one of the “best” outcomes that can result from permanent housing. 

They reintegrate themselves into the community and, consequently, some proportion of 

HUD and other resources are available for other current or prospective residents. 

Situational leavers are also voluntary leavers but less independent than “opportunity 

seekers” and in fact, have difficulty coping with the greater independence required in 

permanent supportive housing. They generally “elect” to leave because they need (and 

sense they need) greater support. They tend to go to facilities with greater support and 

less independence. Their post-permanent housing residential history is generally stable 

and they sometimes may return to permanent supportive housing. 

Involuntary leavers in general have difficulty maintaining a drug/alcohol free lifestyle 

and adhering to program rules. They are more often negatively influenced, as in 

experiencing a relapse, by non-compliant roommates/neighbors, and drug activity and 

drinking establishments, if any, located in close proximity to their residence. Their postpermanent residential careers tend to be less stable than the other leavers. These leavers 

are at the greatest risk and appear to incur the most public costs based on their greater use 

of inpatient and emergency services. 

Factors Associated with Leaving Permanent Housing and Post-Permanent Careers 

Leavers who left involuntarily or went to non-positive locations are by definition at risk. 

Factors associated with leaving permanent housing can potentially be used to identify the 

at risk residents. Several factors, such as level of independent living skills, service use, 

shelter use and psychiatric diagnosis, might well be employed to predict the stability of 

the post-permanent housing residential career of leavers and where leavers will reside 

post permanent housing. Identifying “at risk” residents at the point of entry into 

permanent housing or, at a minimum, early in their tenure could dramatically reduce the 

unfavorable outcomes, provided timely and appropriate interventions are initiated. 

Leavers categorized as positive and/or voluntary tend to have greater independent living 

skills, need less supportive services and have the most favorable housing experience after 

permanent housing. Leavers with the most stable residency tend to be those with the 

greatest independent living skills and the least need for support services. Conversely, 

those with the least independent living skills and the greatest need for supportive services 

tend to have a less favorable housing experience after permanent housing. 

75 
The voluntary leavers categorized as “opportunity seekers” have multiple points of 

contact with the community at large, for example, through attendance at a day program, 

volunteer work, employment and/or working with a therapist. It appears their 

“normalized” lifestyle may contribute to their ability to sustain their residence. Perhaps, 

their relatively high level of interaction enables them to utilize and refine their life skills, 

minimally their capacity to communicate. Additionally, they are most likely to speak of 

their residence as a sanctuary that provides them refuge or solace from the everyday 

demands of their lives. The environment their residence afforded them may have helped 

them cope with some of the issues they have to manage, such as, problems with 

neighbors and building maintenance. 

The voluntary leavers categorized as “situational leavers” were generally pleased with 

their current residence but they expressed more variable levels of satisfaction. They 

made positive references similar to the “opportunity seekers” but also commented on 

their need for more support services and neighborhoods with less drug/alcohol activity or 

establishments. 

Involuntary leavers also expressed satisfaction with their current residence but were more 

likely to go to drug/rehab facilities, shelters or institutions. Possibly, an evaluation that 

incorporates the predictive factors for staying or leaving could have flagged their at-risk 

status. 

Taking into account the limitation of the tracking data, it appears that the leavers with 

whom contact has been maintained have been able to sustain a stable residence, in part, 

because they have reduced their financial burden. Also, a greater proportion of these 

leavers are living in subsidized housing, have reduced their rent, receive Social Security 

Income and Food Stamps and continue receiving mental health services via a therapist. 

Overall, they report they are satisfied with their current residence and have a positive 

assessment of their quality of life. 

IMPLICATIONS AND RECOMMENDATIONS 

These findings suggest that departure from permanent housing is a complex phenomenon. 

Simple dichotomization of “leavers” and “stayers” will not productively guide public 

policy that enhances the effectiveness of permanent supportive housing. In this project, 

departure from permanent housing was categorized according to the circumstances under 

which residents left permanent housing and by the destinations to which leavers 

gravitated. A substantial proportion of leavers moved to residences that required more 

independent living skills and less reliance on supportive services than the permanent 

housing program they left. These outcomes certainly underscored that every “leave” 

cannot be categorized as negative. Moreover, this is the model for those permanent 

housing residents who express a desire to leave and would be categorized as a potential 

“positive” leaver. 

76 
However, regardless of the criteria used, a significant portion of the relatively small 

number who depart under unfavorable circumstances find themselves in homeless or 

institutionalized settings, or in community residential settings requiring higher level of 

supervision and care. This finding demands that for purposes of research and practice we 

identify the risk factors associated with unfavorable departures from permanent housing 

and, to the degree possible, work to prevent such departures by providing appropriate 

housing and support services. The leavers who depart under unfavorable circumstances 

consume a disproportionate share of resources as evidenced by their higher use of 

inpatient and emergency services. 

Based on the integrated longitudinal data analyzed here, basic socio-demographic 

characteristics and generalized measures of level of functioning (such as GAF) taken at 

the point of entering permanent housing do not help us distinguish among stayers, 

leavers who depart under favorable circumstances, and leavers who depart under 

unfavorable circumstances. The “crude” nature of the assessment instruments may 

explain some of this lack of differentiation, particularly existing measures of level of 

functioning and “capability of independent living.” If real differences exist at intake but 

are not detected, more thorough assessment procedures should be introduced to identify 

which homeless individuals would benefit from various combinations of housing and 

support services. 

The findings from this project suggest that service use during residents’ tenure in 

permanent housing may turn out to be one of the most important predictors of either 

staying in permanent housing, leaving under favorable conditions or leaving under 

unfavorable conditions. As both the behavioral health service use administrative data and 

the interview data show, leavers who departed permanent housing under unfavorable 

circumstances were assessed by their residential support staff as having lower levels of 

independent living skills and requiring higher level of assistance and support. This 

finding is supported by the integrated longitudinal data, which indicate that “unfavorable” 

leavers were more likely to use ambulatory services (including intensive case 

management) and community residential services during their tenure in permanent 

housing. The use of community-based behavioral health services aside, perhaps the most 

striking finding is the disproportionate use of homeless services, in-patient psychiatric 

services and emergency psychiatric services among leavers who did not fall within the 

category of positive discharges. The evidence of relapse experienced by leavers who 

departed permanent housing under unfavorable circumstances as indicated by 

hospitalization, return to homeless shelters, and use of emergency services, highlights the 

importance of residential support staff to recognize the “early warning signs” of potential 

“failure” in permanent housing. The challenge is for mental health support staff to 

develop and implement an effective intervention plan to help permanent housing 

residents who are at risk of “failing” in permanent housing because of relapses. It should 

be noted here that for permanent housing residents whose relapses are temporary, 

returning to the permanent housing program should be the intervention goal. But for 

those whose relapses represent an irreversible deterioration of functional and psychiatric 

77 
status, placement in community residential settings with more structure and/or a higher 

level of supervision should be regarded as a successful exit from permanent housing. 

The scenarios for leaving gleaned from the interview data reveal two sets of programlevel characteristics and highlight the importance of environmental factors that may 

affect the likelihood of success among permanent housing residents. Housing 

environmental factors, including the extent of crimes and illicit drug activities in the 

building and at the neighborhood level, were mentioned by leavers as affecting their 

chance of staying sober and their capacity of managing stress, and consequently, their 

opportunity for staying in permanent housing. In contrast, leavers who appear to be 

successful in their post-permanent housing careers time and again cited the desirability of 

their housing and neighborhoods as helping them to stay “focused” and to avoid stressful 

situations. Accounts of adversarial relationships between residential support staff and 

residents, and the persistent inability of some leavers to follow program rules, on the 

other hand, also emerge as precipitating factors in a number of scenarios involving 

involuntary leaving. Importantly, both the housing characteristics pertaining to buildings 

and neighborhoods, as well as the support characteristics pertaining to resident-staff 

relationship and program rules, are factors that can be modified to increase the duration 

of permanent housing stays and enhance the quality of life of permanent housing 

residents. 

Based on the summary and implications, the following recommendations are offered to 

improve the outcomes of permanent housing programming: 

1.	 Permanent supportive housing should continue to be a centerpiece of Federal 

government’s effort to end chronic homelessness. Consistent with the literature 

and reflective of the data, permanent housing is the “housing of choice” for 

homeless mentally ill persons. Rent subsidies provided as part of the permanent 

housing arrangement enable residents to have access to resources, thereby 

enhancing their quality of life. 

2.	 Thorough assessment procedures should be used to match the support needs and 

preferences of permanent housing residents, as well as levels of independent skills 

among prospective permanent housing residents. Evidence from the limited 

existing research indicates that even people who experience chronic street 

homelessness can maintain independent housing with support from staff and with 

a minimal level of program requirements (Tsemberis 1999; Tsemberis et al. 

2003), if services and housing are tailored to the combination of needs and 

preferences of consumers. Clearly, this Housing First approach offers 

possibilities, but it also demands additional cross-site research. The available data 

including preliminary work in Philadelphia support the utility of the model but 

also highlight the fact that this population which is more disabled will require a 

significantly more intense set of support services to be successful in permanent 

housing. 

78 
3.	 Additional evaluations of clients should be conducted at two points: 1) when 

clients are seeking permanent housing and 2) when prospective leavers are 

seeking independent housing. These are two points at which the program may 

have its greatest leverage to influence a client’s participation in supportive 

services or interventions designed to help the client sustain their permanent 

housing and/or achieve a stable residential career. 

4.	 An array of permanent housing programs is required to match the diverse needs 

and preferences of homeless mentally ill persons and the extent of structure and 

supervision that consumers need. Philadelphia’s experience may offer an 

example in this regard, whereby, over time, the City’s Office of Mental Health 

has diversified its housing offerings by converting traditional community 

residential rehabilitation programs that had moderate to maximum levels of 

supervision, into permanent supported housing. As permanent housing, these 

converted units offer clustered apartments, often with peer support from 

consumers. Along with other permanent housing and CRR programs, this 

housing stock offers a broad array of options for maximizing the goodness of fit 

between consumers and housing options. Although the findings in this study did 

not support a statistically significant impact for environmental factors, it may be 

that the limitations and insensitivity in the data sets available to the researchers 

could not reveal the effects. It is important to note that in the client interviews, 

environmental factors were often mentioned by clients as important reasons for 

leaving or staying in permanent housing and further research in the area may be 

useful. 

5.	 Housing agencies should create “early warning systems” to identify permanent 

housing residents at risk for unfavorable discharges. Hospitalizations, arrests, 

eviction warnings, or behavior that places a resident at risk of these events, should 

trigger an intervention by the placement agency, housing agency, and support 

service staff. Upon such an event, an assessment should be made of the 

appropriate resident or support staff adaptations that could be made to ensure 

stability of a given placement, or of the alternative settings in which a resident 

should be placed. Clear protocol should be established which outline when and 

what proactive action should be taken at the time of resident-staff conflict or 

when residential instability is otherwise indicated. 

6.	 The non-positive outcomes and greater cost to serve involuntary leavers suggest 

undertaking further analysis to determine if there is justification to develop 

Permanent Housing specifically designed for repeat drug/alcohol abusers. 

Permanent housing residents “at risk” are often involuntary leavers who have a 

drug/alcohol relapse or are non-compliant with permanent housing rules. These 

residents are costly to serve during their post-permanent housing career. 

Although, a smaller proportion of involuntary leavers use emergency services 

post-permanent housing than during their permanent housing-stay, their use of 

emergency services is more than three times greater than positive leavers. 

79 
7.	 The provision of residential support services need to be recognized as critical and 

integral components of permanent housing. Provision of long-term housing 

subsidy is a necessary but not sufficient condition for success. Permanent 

housing residents have substantial physical and behavioral health needs for which 

appropriate and continuous support is critical to maintain independent living. 

8.	 Careful consideration should be made as to the location of permanent housing, 

and such plans should avoid placing permanent housing residents in 

neighborhoods with high crime rates and drug activities that inadvertently 

increase the risk of relapses for residents. Housing developers and residential 

support staff should also work hand-in-hand in order to improve the building 

environment (lessen the risk of alcohol/drug activities) and to provide a favorable 

environment to the recovery of consumers. 

9.	 The Federal government’s effort to end chronic homelessness should include as 

an objective the re-engagement of homeless persons with SMI who left permanent 

housing. Continuum of Care application requirements could encourage reengagement of such persons as a priority in funding decisions. The development 

of the Homeless Information Management Systems (HMIS) for tracking homeless 

persons both in shelters and in permanent housing is a strong movement in the 

right direction as such a system could theoretically enable a jurisdiction to 

identify people upon shelter admission who might meet this criteria. 

10. Initiatives to help end homelessness should accommodate the desire by many 

current Permanent Housing residents to live in more independent housing. 

Permanent Housing can accommodate this need via, for example, different 

configurations of support reflective of the current service utilization by leavers in 

their post Permanent Housing career. There are numerous benefits that can 

accrue from this progression including: 1) those who leave Permanent Housing 

are less reliant on federal and local resources and sometimes achieve total 

independence from services designated for formerly homeless persons, 2) the 

newly available resources are available to others, and 3) Permanent Housing 

“graduates” may be available to mentor current permanent housing residents who 

aspire to be more independent. Clearly one important finding of this study is that 

leaving permanent housing is not necessarily a negative outcome. The fact that 

clients “move on” to other even more “normal housing” arrangements is not a 

reflection of a failure of the system but of the success of the client. This is also 

very consistent with the recent focus in both policy and research on the 

“recovery” of persons with serious mental illness. This model emphasizes the 

process of recovery over time so that clients are less dependent on the care system 

and more able to integrate into the housing market. The assumption that clients 

will always need the financial and social supports of permanent housing is just not 

consistent with what we know about the lives of persons with serious mental 

illness. 

80 
81
 
APPENDIX A: GLOSSARY OF TERMS 

AACO AIDS Activities Coordinating Office 

AAS Access to Alternative Services 

APR Annual Progress Report 

BHS Behavioral Health System 

CBH City Behavioral Health 

CDBG Community Development Block Grant 

CMHPSR Center for Mental Health Policy and Services Research 

CRS Community Reporting System 

ESG Emergency Shelter Grant 

FUP Follow-up Interview 

GAF Global Assessment of Functioning 

HDC Housing Development Corporation 

HMIS Homeless Management Information System 

ICM Intensive Case Management 

IQV Index of Qualitative Variation 

NIMH National Institute of Mental Health 

OESS Office of Emergency Shelter and Services 

OMH Office of Mental Health 

PDR Progressive Demand Residence 

PH Permanent Housing 

PHA Public Housing Agency 

PSH Philadelphia State Hospital 

RPT Residential Planning Team 

SHDP Supportive Housing Demonstration Program 

SHP Supportive Housing Program 

SIL Supported Independent Living 

S+C Shelter Plus Care 

SRO Single Room Occupancy 

SSI Supplemental Security Income 
APPENDIX B: REFERENCES 
 

Culhane, D.P., Averyt, J.M. and Hadley, T.R., (1997): “The Treated Prevalence of 

Behavioral Health Disorder among Adults Admitted to the Philadelphia Shelter System. 

Results from the Integration of Longitudinal Data on Shelter and Mental Health Services 

Utilization”, Psychiatric Services, 48:3, 390-392. 

Dickey, B., Gonzalez, O., Latimer, E., Powers, K., Schutt, R. and Goldfinger, S. (1996): 

“Use of Mental Health Services by Formerly Homeless Adults Residing in Group 

and Independent Housing”, Psychiatric Services, 47(2): 152-158. 

Fosburg, L., Locke, G., Peck, L., and Finkel, M. (1997): National Evaluation of the 

Shelter Plus Care Program, Washington: U.S. Department of Housing and 

Urban Development. 

Goldfinger, S., Schutt, R., Tolomiczenko, G., Seidman, L., Penk, W., Turner, W., and 

Caplan, B. (1999): “Housing Placement and Subsequent Days Homeless Among 

Formerly Homeless Adults with Mental Illness”, Psychiatric Services 50(5): 

674-679. 

Goldman, Howard H. (2000): The Program on Chronic Mental Illness: PerspectivesFebruary 1, 2000. 

Hadley, T.R., (1996): “Financing Changes and Their Impact on the Organization of The 

Public Mental Health System”, Administration and Policy in Mental Health, 23:5, 393- 

405. 

Hadley, T.R., Turk, R., and McGurrin, M. (1997): “Community Treatment Teams: An 

Alternative to State Hospitals”, Psychiatric Quarterly, 68:1, 77-90. 

Harkness, J., Newman, S., and Salkever, D. (2004): “The Cost-Effectiveness of 

Independent Housing for the Chronically Mentally Ill: Do Neighborhood Features 

Matter?”, Health Services Research. 

Hulbert, M., Hough, R. and Wood, P. (1996): “Effects of Substance Abuse on Housing 

Stability of Homeless Mentally Ill Persons in Supported Housing”, Psychiatric 

Services, 47:731-736. 

Manderscheid, R.W. and Henderson, M.J Mental Health U.S. 1996: Department of 

Health and Human Services, Washington, D.C.: Superintendent of Documents, U.S. 

Government Printing Office. 

Matulef, M., Crosse, S., Ditz, S., Van Ryzin, G., Kiser, M., Puhl, L., and Ficke, R. 
(1995): National Evaluation of the Supportive Housing Demonstration Program: Final 
 

Report, Washington: U.S. Department of Housing and Urban Development. 
 

Ridgway, P., and Rapp, C. A. (1997): The Active Ingredients of Effective Supported 
 

Housing: A Research Synthesis. Lawrence, Kansas: The University of Kansas. 
 

Solomon, P. (1992): “The Closing of a State Hospital: What Is the Quality of Patients'
 

Lives One Year Post-Release?”, Psychiatric Quarterly, 63, 279-296. 
 

Stanhope, V. and Wong, Y.L.I. (2005): “Comparing Neighborhoods for Persons with 
 

Psychiatric and Developmental Disabilities: A GIS Methodology to Evaluate Housing 
 

Approaches”, (Paper presentation) The 5th International Conference on Evaluation and 
 

Practice, Huddersfield, England, July, 2005. 
 

Stanhope, V., Wong, Y.L.I., and Hillier, A.H. (2005): “Conceptualizing Community: A 
 

Comparison of Neighborhood Characteristics of Supportive Housing for Persons with 
 

Psychiatric and Development Disabilities.” (Poster Presentation) Ninth Annual 
 

Conference of the Society for Social Work and Research, January 2005. 
 

Stiles, P.G., Culhane, D.P., and Hadley, T.R. (1996): “Before and After 
 

De-institutionalization: Comparing State Hospital Utilization, Staffing and Costs in 1949 
 

and 1988”, Administration and Policy in Mental Health, 23:6, 513-526. 
 

Susser, E., Valencia, E., Conover, S., Felix, A., Tsai, W., and Wyatt, R. (1997). 
 

“Preventing Recurrent Homelessness among Mentally Ill Men: A ‘Critical Time’ 
 

Intervention after Discharge from a Shelter”, American Journal of Public 
 

Health 87:256-262. 
 

Tanzman, B. (1993): “An Overview of Surveys of Mental Health Consumers’ 
 

Preferences for Housing and Support Services”, Hospital and Community Psychiatry, 
 

44(5), 450-455. 
 

Toro (2002): “Trials, Tribulations and Occasional Jubilations While Conducting 
 

Research on Homelessness”, Wayne State Department of Psychology.
 

Tsemberis, S. J., Moran, L., Shinn, M., Asmussen, S. M., and Shern, D. L. (2003): 
 

“Consumer Preference Programs for Individuals Who are Homeless and Have Psychiatric 
 

Disabilities: A Drop-in Center and a Supported Housing Program”, American Journal of 
 

Community Psychology, 32(3), 305-317. 
 
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APPENDIX C: 
 

LEAVER BASELINE DISCUSSION GUIDE
 

1a We would like you to tell us your situation before you entered permanent housing. 

(Probe: Personal situation. Living situation. Type of place/housing. If type is unfamiliar, 

probe for specifics. Get sequence of housing prior to PH program.) 

1b. What did you hope would happen in the PH program? (Probe: Motivation for 

entering program, what did they hope the program would accomplish, what were their 

expectations? Was there any critical information that was not thoroughly explained 

upfront or prior to entrance). 

1c. What was your experience like living in permanent housing and receiving support 

from (NAME OF HOUSING PROGRAM)? (Probe: Activities. Assess reactions, do they 

feel positive or negative about what they are reporting?) 

2a. We’d like you to tell us your experience of homelessness. Since you turned 18 

(or you became an adult) and prior to your placement in (NAME OF PH PROGRAM), 

about how many times would you say you have been homeless? 

2b. Since you turned 18 (or you became an adult) and prior to your placement in 

permanent housing, what is the total amount of time you have been homeless? Note: An 

episode of homelessness ends when you have a place to live for a week or longer.) 

3a. What is the situation under which you left (NAME OF PH PROGRAM)? Probe: 

Would you tell us some specific reasons that made you leave permanent housing? (Be 

sure to uncover underlying reasons for leaving, and determine the most important reason. 

Then, circle appropriate reasons in “unaided column”) Probe: Do you feel that (insert 

name of provider) would agree? How do you feel that their opinion would differ? 

Interviewer: Be sensitive to the possibility that the client may take this query to mean 

that they are not telling the truth or are giving an inaccurate account of the situation. 

3b. Aided Question. I would like to read a list of reasons others have given for 

leaving permanent housing programs, and these reasons may or may not apply to you. 

Would you say that you left the program because (read list and circle 1 or 2). (Probe for 

clarification: “Asked to leave” or “Opportunity to move to more desirable housing”. 

Note: Be careful when probing elements that the client did not introduce.) 

3c. Do you consider your departure from (NAME OF PH PROGRAM) voluntary or 

involuntary? (Record all comments, both initial and subsequent. The client may be 

ambivalent about leaving and we want to capture this in the data.) 

3d. Did you reach the end of your eligibility for housing and/or services there? 

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4a. We would like you to tell us all the different places you have been staying after 

leaving (NAME OF PH PROGRAM), starting with your current residence. Did you come 

to live here directly from (NAME OF PH PROGRAM)? If no, continue with the 

residence(s) prior to the current one. Be sure to obtain complete address and date of move 

in for each residence.) 

For each of the places mentioned, probe: Determine or ask, (1) What type of place is/was 

it? (2) Whom do you/did you live with in that place? (3) Do you /did you own or rent 

that place, or are you just staying there? (4) If the place is rented, does a government 

program cover any of the rent? (e.g., section 8 or 1260) (5) Do/did you personally pay 

any rent or mortgage for staying in your current residence, or do you contribute any 

money in order to stay there? (6) About how much do you pay each month? (7) Do you 

receive basic support in handling your personal responsibilities (i.e. budgeting, keeping 

appointments, transportation, dealing with landlord/housemates/neighbors, etc.) (Record 

type of residence in appropriate column/row.) 

4b. Are you receiving services or treatment from any of the following: case manager, 

therapist, psychiatrist, psychiatric nurse? Or some other individual? A mental health 

care provider? If yes: What is the name of the program that provides these services or 

treatment for you? (Obtain name of individual and name of program.) If no: What about 

since you left PH? 

5a. How did you feel about your life in general when staying in PH and receiving 

support from (NAME OF PH PROGRAM)? (Probe: Reasons behind their feelings. 

Anything else? Is there anything specific about the program that they liked or disliked 

but have not yet mentioned?) 

5b. If you had to select one of the feelings on this scale (show scale), how would you 

describe how you felt about your life in general when staying in PH. (Probe further if 

answer is very different from verbal description). 

6. Now I would like to ask you some questions about your activities such as work 

and school. (Use list as guide.) Are you currently working at a job for pay? Is that full 

or part time? What type of job is it? Are you currently engaged in other activities, such 

as doing volunteer work, attending school, participating in job or skill training, or 

attending a structured day program? Are there any other activities that you are involved 

in? (Record type of job, schooling or program in the space provided.) 

7a. I would like to ask you briefly about your financial support? What kinds of 

financial support are you receiving currently? (Probe: items on list.) Are there any other 

sources of income I didn’t mention? 

7b. About how much money did you receive during the past month from all sources 

of income? 

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8a. How do you currently feel about your life in general? 

8b. Using the same scale as before (show scale), how would you rate your feelings 

about your life in general at the present time. (Probe further if numerical rating is very 

different from verbal description). 

9. Now I have a few questions in closing. (INTERVIEWER: Obtain level of 

education, age, race they consider themselves to be, number of children with ages and 

gender if children previously mentioned.) 

10. Do you have any closing comments or questions for me? 

REMEMBER TO RECORD “Compliance/Reliability Score” on a scale of 1 to 10. 

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APPENDIX D: 

LEAVER FOLLOW-UP DISCUSSION GUIDE 

1. We would like you to tell us all the different places you have been different places 

you have been staying since our last interview with you, starting with you current 

residence. For each of the places mentioned, probe: What type of place is/was it? Who 

do/did you live with in that place? Do/did you own or rent that place, or are/were you just 

staying there? If the place is rented, does/did a government program cover any of the 

rent? Do/did you personally pay any rent or mortgage for staying in the residence, or 

do/did you contribute any money in order to stay there? About how much do/did you pay 

each month? Do/did you receive basic support in handling your personal responsibilities 

(i.e. budgeting, keeping appointments, transportation, dealing with landlord/ 

housemates/neighbors, etc.) as part of the living arrangement? Are you receiving 

services or treatment from any of the following: case manager, therapist, psychiatrist, 

psychiatric nurse? Or some other individual? a mental health care provider? Probe: What 

is/are the name(s) of the program(s) which provide these services or treatment for you? 

2. Are you currently working for a job for pay? What type of job is it? Are you 

currently engaged in other activities, such as doing volunteer work, attending school, 

participating in job or skill training, or attending a structured day program? 

3. What kinds of financial support are you receiving currently? About how much 

money did you receive during the past month from all sources of income? 

4. How do you feel about your current residence (on the Terrible – Delighted 

Scale)? How do you feel about your life in general (again on the Terrible – Delighted 

Scale)? 

5. Some people who left permanent housing with support services like returning to 

such housing while other people dislike that. If you had a choice, would you consider 

returning to permanent housing and receiving support services from a program staff? 

Please tell us the reason. 

REMEMBER TO RECORD “Compliance/Reliability Score” on a scale of 1 to 10. 

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APPENDIX E: 
 

STAYER BASELINE DISCUSSION GUIDE 
 

1a. We would like you to tell us your situation before you entered permanent housing. 

(Probe: Personal situation. Living situation. Type of place/housing. If type is unfamiliar, 

probe for specifics. Get sequence of housing prior to PH program.) 

1b. What did you hope would happen in the PH program? (Probe: Motivation for 

entering program, what did they hope the program would accomplish, what were their 

expectations? Was there any critical information that was not thoroughly explained 

upfront or prior to entrance)? 

1c. What is your experience like living in permanent housing and receiving support 

from (NAME OF HOUSING PROGRAM)? (Probe: Activities. Assess reactions, do they 

feel positive or negative about what they are reporting?) 

2a. We’d like you to tell us your experience of homelessness. Since you turned 18 

(or you became an adult) and prior to your placement in (NAME OF PH PROGRAM), 

about how many times would you say you have been homeless? 

2b. Since you turned 18 (or you became an adult) and prior to your placement in 

permanent housing, what is the total amount of time you have been homeless? Note: An 

episode of homelessness ends when you have a place to live for a week or longer.) 

did not introduce.) 

3a. How would you describe your current living arrangement? (Probe items on list.) 
 

3b. When did you move in? 
 

3c. How much do you pay for rent per month?
 

4. Are you receiving services or treatment from any of the following: case manager, 

therapist, psychiatrist, psychiatric nurse? Or some other individual? A mental health 

care provider? What is the name of the program that provides these services or treatment 

for you? (Obtain name of individual and name of program.) (Note: They would be 

receiving some services if they are in PH program.) 

5a. How do you feel about your life in (NAME OF PH PROGRAM) and receiving 

support from them? (Probe: Reasons behind their feelings. Anything else? Is there 

anything specific about the program that they liked or disliked but have not yet 

mentioned?) 

5b. If you had to select one of the feelings on this scale (show scale), how would you 

describe how you feel about your life in (NAME OF PH PROGRAM). (Probe further if 

answer is very different from verbal description). 

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6. Now I would like to ask you some questions about your activities such as work 

and school. (Use list as guide.) Are you currently working at a job for pay? Is that full 

or part time? What type of job is it? Are you currently engaged in other activities, such 

as doing volunteer work, attending school, participating in job or skill training, or 

attending a structured day program? Are there any other activities that you are involved 

in? (Record type of job, schooling or program in the space provided.) 

7a. I would like to ask you briefly about your financial support? What kinds of 

financial support are you receiving currently? (Probe: items on list.) Are there any other 

sources of income I didn’t mention? 

7b. About how much money did you receive during the past month from all sources 

of income? 

8a. How do you currently feel about your life in general? 

8b. Using the same scale as before (show scale), how would you rate your feelings 

about your life in general at the present time. (Probe further if answer is very different 

from verbal description). 

9. Some people prefer to live in permanent housing with support services while 

other people want to move on to other living arrangements. If you had a choice, would 

you prefer to stay in permanent housing and receive support services from a program 

staff or to move on to another living arrangement? Would you tell us the reason for your 

thinking that way? 

10. Now I have a few questions in closing. (INTERVIEWER: Obtain level of 

education, age, race they consider themselves to be, number of children with ages and 

gender if children previously mentioned.) 

11. Do you have any closing comments or questions for me? 

 E.2 
APPENDIX F: 
 

LEAVER/STAYER CONSUMER BACKGROUND WORKSHEET
 

(TO BE COMPLETED BY PROVIDER) 
 

I. DATE OF DEPARTURE: (To be filled out for leavers only; note that this is for 

verification purpose only. Dates of admission and departure for all participants are 

recorded in the administrative database maintained by the Office of Mental Health) 

Please write the date when the consumer left the residential support program. 

DATE OF DEPARTURE 
 

Month Day Year 

II. CIRCUMSTANCES OF LEAVING (to be filled out for leavers only) 

Please describe the circumstances upon which the consumer left the residential support 

program. 

 F.1 
III. NATURE OF LEAVING (to be filled out for leavers only) 

Do you consider the circumstances upon which the consumer left the program voluntary 

or involuntary on the part of the consumer? 

Voluntary 1 

Involuntary 2 

 F.2 
The following questions will be asked of both leavers and stayers. 

IV. LEVEL OF FUNCTIONING 

Please rate how regularly the consumer demonstrated the following skills at the point of 

his/her leaving the program(leavers only) or today for stayers: 

(ANSWER EACH ITEM) Never Rarely Sometimes Often Always 

Self-care and self-preservation: Bathes, 

grooms, toilets, dresses, ambulates, responds 

appropriately to danger etc. 

1 2 3 4 5 

Food management: Plans menus, purchases 

food, plans meals, cleans up, etc. 1 2 3 4 5 

Money management: Budgets and manages 

money so as to meet needs 

1 2 3 4 5 

Medication management: Is familiar with and 

is willing to comply with medication regimen 1 2 3 4 5 

Transportation: Uses the public 

transportation system, or has other supports 1 2 3 4 5 

Independence: Plans, organizes own time 

and/or is willing to participate in planned 

day/evening events 

1 2 3 4 5 

V. BEHAVIORAL CHARACTERISTICS 

Please check if the consumer had the following behavioral characteristics during his/her 

stay in the residential support program. (Leavers and Stayers) 

(ANSWER EACH ITEM) Yes No 

Fire-setting 1 2 

Substance abuse 1 2 

Homicidal behavior 1 2 

Assaultive behavior 1 2 

Self-injurious behavior 1 2 

Suicidal attempts 1 2 

Forensic involvement (i.e., criminal justice system) 1 2 

Other antisocial behavior (SPECIFY): 1 2 

F.3 
 
VI. SUPPORTS & SERVICES 

(Leavers and Stayers) 

Think about an average consumer in your residential program. By “average consumer,” 

we mean someone who receives an average amount of support and help from program 

staff relative to all other consumers in your program. Please rate how much support and 

help this consumer was receiving on average compared to other consumers. 

(ANSWER EACH ITEM) 

Much less 

than 

average 

Slightly 

less than 

average 

Average 

Slightly 

more 

than 

average 

Much 

more 

than 

average 

Service 

Not 

Available 

Dealing with landlord, housing 

manager, housemate, and neighbors 1 2 3 4 5 6 

Self and personal care 1 2 3 4 5 6 

Food management 1 2 3 4 5 6 

Money management 1 2 3 4 5 6 

Medication management 1 2 3 4 5 6 

Transportation (including 

appointment, work, and recreation) 1 2 3 4 5 6 

Goal planning and time management 1 2 3 4 5 6 

Making appointments and 

arrangements for medical and 

psychiatric care 

1 2 3 4 5 6 

Dealing with stress and emotional 

upset 1 2 3 4 5 6 

Dealing with crisis 1 2 3 4 5 6 

Development of natural support 

networks, including family members 

and friends 

1 2 3 4 5 6 

Connecting with social services 1 2 3 4 5 6 

Employability/Employment Skills 1 2 3 4 5 6 

F.4 
 
 F.5 
 
 F.6 
 
U. S. Department of Housing and Urban Development 

HUD USER 

P.O. 23268 First Class Mail 

Washington, DC 20026-3268 Postage and Fees Paid 

Permit No. G-795 

Official Business 

Penalty for Private Use $300 

March 2006