Supportive Housing Helps Vulnerable People Live and Thrive in the Community

Everyone needs safe, decent, stable housing.  For some of the most vulnerable people in America — people with mental illness, chronic health conditions, histories of trauma, and other struggles — a home helps them to get adequate treatment and start on the path toward recovery.  But some conditions make it difficult for people to maintain a stable home without additional help.  Supportive housing, a highly effective strategy that combines affordable housing with intensive coordinated services, can provide that needed assistance.

Living without stable housing can drastically worsen health.  Homelessness can exacerbate mental illness, make ending substance abuse difficult, and prevent chronic physical health conditions from being addressed.  People with these and other health issues often end up in crisis situations while living on the streets, and emergency rooms may be the only health care they are able to access.

Although affordable housing is part of the solution, some people may need their housing coupled with supportive services to maintain it.  For instance, service providers can help people with mental illness pay their rent on time and understand the rights and responsibilities outlined in a lease, or can make sure people with chronic illnesses manage their diet and medicine properly, which can keep them out of hospitals or nursing homes.

A broad body of research shows that supportive housing effectively helps people with disabilities maintain stable housing.  People in supportive housing use costly systems like emergency health services less frequently and are less likely to be incarcerated.  Supportive housing also can aid people with disabilities in getting better health care and help seniors trying to stay in the community as they age and families trying to keep their children out of foster care.

Policymakers, administrators, and health providers are increasingly aware that a lack of stable housing can interfere with health goals, and that linking health care with affordable housing can produce better outcomes for some people than providing them separately.  Yet there is not nearly enough supportive housing to meet the need.  Policymakers can create additional supportive housing by:

• Providing additional rental assistance and other housing resources;
• Reinvesting savings created by supportive housing that reduces use of health services and corrections to increase the supply of rental assistance;
• Making greater use of Medicaid services for supportive housing; and
• Targeting supportive housing only on those who need it.

Essential Characteristics of Supportive Housing

Supportive housing is a highly effective strategy that combines affordable housing with intensive coordinated services to help people struggling with chronic physical and mental health issues maintain stable housing and receive appropriate health care.  Supportive housing features:

Permanence and affordability.  Tenants generally pay no more than 30 percent of their income for rent.  They have the same rights and responsibilities as other renters, such as having the lease in their name and the right to privacy in their unit, which means they cannot be evicted for reasons unrelated to being a good tenant.

A core set of service principles.  They are:

• Services are housing-oriented.  Services aim to help tenants remain housed.  Service providers help people find suitable housing, build relationships with their landlords, and understand their rights and responsibilities as renters.  Providers also intervene to prevent evictions.
• Services are multi-disciplinary.  Service providers also help tenants address physical health, mental health, and substance use conditions, and help with other issues like applying for Social Security benefits or gaining employment.  Teams of professionals such as mental health and substance use specialists, nurses or doctors, and case managers provide care.  Services must be flexible enough to address each individual tenant's needs, which may involve multiple service agencies working together.  These teams also try to link people to mainstream service systems like work training, if appropriate
• Services are voluntary but assertive.  Services are voluntary; tenants will not lose their housing simply because they do not participate in services.  But providers offer supportive services assertively, which means that they will continue to show up and check on someone even if tenants don’t request help.

Integration.  Individuals and families are able to live independently in apartments or single-family homes in residential neighborhoods.  Tenants in supportive housing should have access to public transportation, grocery stores, parks, and other neighborhood amenities common to all other residents.  Services are usually provided in the client’s unit or building, or at a place of their choosing in the community, and clients should not lose access to services if they choose to live somewhere else.  (Less accessible services put tenants’ housing and health at risk: if they are unable to travel to providers’ offices, for instance, they may stop using the services.)

Emphasis on choice.  Supportive housing maximizes client choice, in clients’ housing options and the services they receive.  For instance, tenants can generally come and go as they please and have control over their daily schedule, like mealtimes and visitors.  They also can direct the types of services they receive and the goals they set with the service provider.

Low barriers to entry.  Supportive housing providers do not require clients to hit benchmarks before moving into housing or put other screening barriers in the way.  Blanket bans on people with criminal histories or bad credit, for example, or requirements to meet goals, like employment or completing a course of treatment, before entering supportive housing would screen out the very people supportive housing aims to help.

Other models combine housing and services but are not supportive housing, although the lines between models are not always bright.  Nursing homes, for instance, restrict residents’ choice and do not allow them to live in the community.  Other models use affordable housing as a platform to improve residents’ health and quality of life — often called “service-enriched housing” — but the services they provide, like in-home nutrition classes for the elderly, are not necessary for residents to maintain stable housing.

Evidence Backs Supportive Housing

A large body of research shows that the vast majority of people who live in supportive housing are able to stay stably housed in the community.  Research has also examined the effect of supportive housing on other outcomes, like mental and physical health, and the use of health care systems, corrections, and other systems.

Most of this research focuses on people with severe disabilities experiencing homelessness, especially people with mental illness or substance use disorders as well as other chronic physical health issues like HIV/AIDS.^[2]  A few more recent studies evaluate supportive housing for other groups, such as seniors and families.

The research supports four main conclusions:

• Supportive housing helps people with disabilities live stably in the community.
• People with disabilities in supportive housing reduce their use of costly systems, especially emergency health care and corrections.
• Supportive housing can help people with disabilities receive more appropriate health care and may improve their health.
• People in other groups, including seniors trying to stay in the community as they age and families trying to keep their children out of foster care, likely also benefit from supportive housing.

Building on this strong body of research, supportive housing practice is expanding to help other vulnerable people, such as homeless youth,^[3] who often have spent time in the foster care system and struggle with mental health issues and trauma, and people with developmental disabilities, who often live in segregated group homes rather than being integrated into the community.  The existing research suggests that supportive housing would be successful for such other groups, but researchers should continue to examine how supportive housing’s impact might differ for them.

Supportive Housing Helps People With Disabilities Live Stably in the Community

In studies conducted of this population, at least 75 percent of homeless people with mental illness or other serious disabilities (including those who have been homeless for long periods) who entered supportive housing as part of such a study remained through the study’s end (usually 18 to 24 months).  Although few studies have followed tenants for much longer, of those that have, at least half of the tenants stayed for as long as five years.^[4]  

Supportive housing achieves much better housing stability than case management without rental assistance.^[5]  Tenant housing stability in supportive housing is similar to stability in more segregated housing and service models like group homes and nursing homes, but tenants highly prefer supportive housing.^[6]  The success seems to hold for a range of disabilities — people with physical disabilities or chronic illnesses such as HIV/AIDS fare well in supportive housing,^[7] as do people with severe mental illness or substance abuse disorders.^[8]

People with disabilities who lived in supportive housing after release from jail or prison were 61 percent less likely to be re-incarcerated one year later than those not offered supportive housing.People with mental illness and other severe disabilities are also more likely than others to be incarcerated or to enter long-term health care institutions like nursing homes or psychiatric hospitals, or to cycle between institutionalization and homelessness.^[9]  Many studies show that supportive housing successfully interrupts this cycle — people with histories of incarceration or institutionalization significantly reduce their use of those systems after moving into supportive housing.  One of the largest studies to date that documents these reductions, conducted in New York City, found that individuals placed in supportive housing spent, on average, 115 fewer days per person in homeless shelters, 75 fewer days in state-run psychiatric hospitals, and almost eight fewer days in prison or in jails, in the two years after entering supportive housing, compared to a similar group without supportive housing.^[10]

Most studies recruit people from homeless shelters or off the streets, but a few small studies use supportive housing to help people move out of nursing homes or other institutions.^[11]  One found that a group in supportive housing recruited from psychiatric hospitals moved quickly out of the institutions and avoided subsequent homelessness, while a group without supportive housing exited institutions much more slowly and experienced more homelessness two years later.^[12]

The research on supportive housing designed to move people with disabilities directly out of jails or prisons is limited to a few studies, most of which are case studies.  One of the most recent and well designed tracked 121 participants who lived in supportive housing after release and 118 who did not.  Those in supportive housing were 43 percent less likely to be rearrested on misdemeanor charges (though there was no difference in the likelihood of felony arrests), and were 61 percent less likely to be re-incarcerated one year later.^[13]

Supportive Housing Reduces the Use of Other Costly Systems

Many researchers and policymakers are now trying to understand to what extent associated reductions in the use of homeless shelters, prisons and jails, and health care — including emergency room visits, inpatient hospitalizations, and stays in nursing homes or psychiatric hospitals — can offset the cost of supportive housing.

The results of the existing studies vary somewhat in the magnitude of the cost reductions and the particular systems affected.  One of the larger studies found reductions mostly in the homelessness system,^[14] while a number of others found reductions across multiple systems like the study in New York, referenced above, in which use reductions offset about 95 percent of the cost of the supportive housing.

The evidence suggests that the greatest reductions are likely achieved with supportive housing that focuses on people who are the costliest utilizers of services.  People experiencing homelessness are not homogenous: a study in Philadelphia that tracked the costs of services used by people with disabilities who were homeless for a long time found that about 20 percent of that group accounted for 60 percent of the health care, corrections, and homeless services costs (see Figure 1).^[15]  Targeting less frequent users may not significantly impact other systems or save money.

A large-scale study in Canada compared high- and moderate-need groups of homeless individuals with mental illness.^[16]  Two years after they were offered supportive housing, both groups had high rates of stable housing, but only the high-needs group reduced use of health care and corrections systems.  The moderate-need group actually increased its use of health care, likely because supportive housing provided better access to appropriate health services.^[17]  (Other studies have shown similar increases in outpatient services after entering supportive housing.)  

One well-designed study targeted a particularly high-needs group and found that savings in the health care system could be substantial.^[18]  The study recruited homeless, hospitalized people with chronic illnesses that have a high risk of mortality.  On average, people offered supportive housing spent 23 percent fewer days in hospitals, had 33 percent fewer emergency room visits, and spent 42 percent fewer days in nursing homes, per year during the study period, among other positive results.^[19]  The study estimated that these reductions (and others) more than offset the cost of supportive housing, resulting in over $6,000 in annual savings per person (see Figure 2).  Although this study focused on a very specific population — so working with a different group may not produce similar results — it illustrates the potential cost savings of providing a high-needs group with supportive housing.

Promising Findings Suggest Supportive Housing May Improve Health

Supportive housing helps people get appropriate care for their health conditions by reducing use of emergency health services and increasing use of outpatient services.  Due to a focus on housing stability as supportive housing’s primary goal, there have not been many studies on the mental or physical health outcomes (such as improved diabetes management, lower blood pressure, and controlled chronic conditions) of people in supportive housing.  More high-quality research on health outcomes is needed.

The strongest findings in this area show that supportive housing reduces the risk of death among the small subset of people with HIV/AIDS, and may also lessen the amount of the virus in their bloodstream.^[20]  In a separate analysis of the high-needs group study referenced above, participants with HIV/AIDS in supportive housing were 63 percent more likely to be alive and have an intact immune system — a measure of disease progression — than those in the control group.^[21]  Other studies have found similar increases in survival among people with HIV/AIDS in supportive housing.^[22]

Few supportive housing studies track mental health outcomes.  A few more track substance use, but only a handful compare groups with and without supportive housing.^[23]  Among those that use comparison groups, some find that people in supportive housing do not differ in their substance use from those who are not in supportive housing,^[24] but one notable study found large reductions in alcohol and other drug use after homeless veterans were randomly assigned to receive supportive housing.^[25] 

Getting an accurate picture of substance use, especially among the groups without supportive housing, is extremely difficult for a number of reasons, especially the unreliability of self-reports of drug use and low response rates to follow-up among those without supportive housing.  The study that found reductions in substance use is the only one that specifically adjusted for these differential follow-up rates. ^[26] 

“… participants with HIV/AIDS in supportive housing were 63 percent more likely to be alive and have an intact immune system.”A majority of the evidence on behavioral health in supportive housing simply compares substance use and mental health symptoms before and after entering supportive housing (rather than using comparison groups).  These studies show consistently that those in supportive housing reduce their use of substances over time, and at least one study shows a reduction in mental health symptoms as well.^[27]   Together the available studies indicate that supportive housing works at least as well as other treatments available in the community to help people experiencing homelessness reduce their substance use and may be more effective.

Clearly, more high-quality research is needed, especially research that examines the type of mental health and substance use services that are widely used in supportive housing.  For example, there is strong evidence that a treatment model called Assertive Community Treatment (ACT) reduces psychiatric symptoms and increases housing stability for people with severe mental illness who are experiencing homelessness,^[28] and a technique called Motivational Interviewing (MI) has been shown to reduce drug and alcohol use.^[29]  Yet no supportive housing study specifically tests the effect of different behavioral health treatment models.  There is no reason to believe that ACT, MI, or other evidence-based treatment models would be less effective in stable housing, but researchers should evaluate whether different treatments could be more effective when administered as part of supportive housing.

Other Groups Can Benefit From Supportive Housing

Additional limited research shows that supportive housing is a promising model for helping people in other groups, including seniors trying to stay in the community as they age and families trying to keep their children out of foster care.

Model Likely Can Help Frail Seniors Age in the Community

Some homeless people with severe disabilities are elderly.^[30]  But other seniors who have never needed support before may find it difficult to stay in their homes as their health worsens.  Supportive housing can likely help these seniors avoid or delay entry into nursing homes and other care facilities, although only a few studies have examined the use of supportive housing for this purpose. 

One study provided supportive housing to seniors already living in affordable housing and compared their rates of nursing home admission and hospitalization to seniors in affordable housing in the same community without supportive housing.^[31]  Seniors in buildings in which supportive housing was offered were half as likely to enter nursing homes as seniors in the buildings without supportive services.^[32]  Individuals with supportive housing were also much less likely to go to the hospital.  This is consistent with broader health care research that finds that in-home support for seniors can effectively reduce their rate of admission to nursing homes.^[33]

Supportive Housing Can Help Keep Families Together

Many families with children struggle with severe disabilities and homelessness.  The few supportive housing studies that include families show results similar to those for homeless individuals.^[34]

Keeping a family intact while struggling with homelessness and mental illness is difficult.  Separation is very common for homeless families: children in families experiencing homelessness often live separately from their parents, and they have an elevated risk of involvement with the child welfare system.^[35]  Affordable housing alone would enable many homeless families to remain together: a recent major study showed that children in homeless families offered rental assistance, with no additional services provided, had fewer placements in foster care.^[36]

A small group of families likely needs supportive housing to stay intact.  Similar to single adults who are frequent users of health care and correctional systems, a subgroup of families are frequent users of the child welfare system.  Research on these families indicates that they have higher rates of mental health and substance use issues, and they experience long-term financial instability that severely limits their ability to pay for rent, heat, food, health care, and other essentials.^[37] 

The Keeping Families Together demonstration examined supportive housing targeted on families that were involved in the child welfare system and had other service needs.  The study began as a small pilot project in New York City that served 29 child welfare-involved families that had been homeless for long periods of time and had a parent with a disabling condition.  The families had been homeless for at least ten months (and for up to 12 years), and almost all struggled with mental illness or a history of substance use.  About half of the families had two or more child welfare cases in the three years prior to moving into supportive housing, and less than half of the children in these families were living with their birth parents at the time of move-in.  Over 60 percent of the child welfare cases that were open when families moved in were subsequently successfully closed, all of the children who were in foster care with a goal of reunification were reunited with their families, and reports of child abuse or neglect dropped from an average of 2.1 incidents per family to 0.6 incidents per family after moving into supportive housing.^[38]  The Department of Health and Human Services is implementing and testing a five-site demonstration to expand this model.^[39]

Bringing Supportive Housing to Scale

Despite its effectiveness, few of the people who would benefit most from supportive housing actually receive it.  There are no exact estimates of either the need for or supply of supportive housing, though there are some good data on homelessness.^[40]  To meet the need, policymakers should consider four interrelated strategies to expand supportive housing:

• Provide additional rental assistance and development resources;
• Reinvest savings created by supportive housing to add to the stock of rental assistance;
• Increase the use of Medicaid services for supportive housing; and
• Target supportive housing only on those who need it.

Expanding Rental Assistance and Supportive Housing Development

Most rental assistance is federally funded, yet only one in four eligible low-income households receives assistance.^[41]  Expanding available rental assistance is essential to meeting the need for supportive housing.  A number of options are available to federal, state, and local policymakers to expand rental assistance.    

• Expand the Housing Choice Voucher program.  Vouchers used for supportive housing have played a major role in reducing veterans’ homelessness in recent years.^[42]  Additional housing vouchers could play a critical role in bringing supportive housing to scale to help other needy individuals and families.  Vouchers are the only major form of federal rental assistance that can be expanded to serve more households^[43] and are particularly well-suited for supportive housing.  Housing Choice Vouchers can be tenant-based or project-based,^[44] allowing communities flexibility over how they implement supportive housing.  Unlike other project-based rental assistance, project-based vouchers allow tenants to move out of the unit with an available tenant-based voucher after one year (while the subsidy stays with the unit).  This ensures that tenants do not risk losing housing assistance if they wish to live somewhere else and allows tenants to move out of supportive housing if they no longer need it (more on this below).  Policymakers could encourage public housing agencies to use a portion of new vouchers for supportive housing where needed.
• Expand smaller federal programs that provide rental assistance to special populations.  A number of smaller programs provide rental assistance to certain groups such as people experiencing homelessness, seniors, non-elderly people with disabilities, and people living with HIV/AIDS (see appendix for a list of federal rental assistance programs and the people served by each program). Recent increases in supportive housing for the chronically homeless, mainly through McKinney-Vento Homeless Assistance Grants, which provide long-term rental assistance for supportive housing, have helped drive a 30 percent decline in chronic homelessness since 2007.^[45]  Programs targeting other populations can provide supportive housing if properly targeted and combined with services. 
• States could fund additional rental assistance.  Massachusetts, for instance, funds supportive housing for about 1,300 households.  At least 34 states have at least one program that provides housing assistance to low-income people, which often are used for supportive housing.^[46]
• Service providers and advocates could build partnerships with housing providers to help them target more federal rental assistance for supportive housing.  State and local program administrators can target vouchers and subsidized units that become available on specific populations to provide supportive housing, but they are not required to, and few currently do so.^[47] 
• State and federal policymakers could direct more development resources to supportive housing.  Especially in certain high-cost, low-vacancy areas and some rural areas where rental assistance alone may be difficult to use, development subsidies are needed to create more supportive housing.  The federal Low Income Housing Tax Credit (LIHTC) is the largest source of development funds,^[48] and the National Housing Trust Fund (NHTF)^[49] will become another important source of development funding beginning this year.  The NHTF requires that the housing be targeted on much lower-income households than LIHTC.  Coupling project-based Housing Choice Vouchers with LIHTC or other development funds can be especially helpful for building or rehabilitating new supportive housing.  The dedicated income that a project-based voucher ensures can help to raise additional funding for a project, possibly increasing the number of units that get built.  State agencies that allocate tax credits and trust funds to projects could better target them for supportive housing, based on an assessment of local need.  To be most effective in increasing the availability of supportive housing, any federal expansion of development funds should also include an expansion of rental assistance.

Reinvesting Savings

States and localities should reinvest some of the savings that supportive housing produces in systems like corrections and health care to provide more rental assistance.  To produce savings sufficient to merit reinvestment, states or localities must target individuals who are the costliest users of these systems.  While demonstrating savings and achieving consensus on reinvestment can be significant challenges, states may be best situated to create such initiatives, since a state could aggregate savings from multiple systems.  If the savings are large enough, counties, cities, and other entities (see example below) could reinvest savings as well.

California and New York are taking steps, through section 1115 Medicaid waivers, to reinvest savings in supportive housing.  California now explicitly offers counties the opportunity to form pilots that allow entities in the county, including health care plans, public hospitals, charitable organizations, and others, to contribute to county-based housing funding pools.  Contributions can come from savings achieved in reduced jail, emergency room and homeless shelter utilization by implementing programs such as supportive housing.  The pilot can reinvest the funds in these pools to expand affordable housing, which may help further drive down costs if this housing is targeted to costly groups and combined with services.^[50]  New York is projecting potential state health care savings from supportive housing and using those funds to provide rental assistance and capital grants for supportive housing.^[51]  Neither model has been fully implemented yet, and accurately tracking the savings is difficult, but they present promising paths forward for this approach.

A number of communities have employed an innovative practice called Pay for Success financing to help build the evidence for creating savings through supportive housing.  Pay for Success is a public-private partnership in which private investors provide the necessary up-front funding to initiate a certain program (like supportive housing) with clear goals and are paid back only if the program meets those goals.  Some communities have used this model to fund supportive housing to reduce costs in health care or corrections.  While few of these initiatives have results yet, and they are not a substitute for additional government investment in supportive housing, Pay for Success is another promising approach to help jumpstart new supportive housing initiatives.

Increasing the Use of Medicaid to Provide Supportive Services

Most federal grant programs that fund supportive services are time-limited and funded at levels too low to meet the need (see appendix for a list of the major federal services programs).  Medicaid is available to anyone who qualifies, so it provides a much larger, more predictable source of health and supportive services funding.  Some states have increasingly leveraged Medicaid as a source of services funding for supportive housing, but it is still underutilized for this purpose.  States can take multiple steps to expand the availability of services for supportive housing through Medicaid.  They can:

• Expand Medicaid.  Health reform gave states the opportunity to expand their Medicaid programs to cover nearly everyone whose income is at or below 138 percent of the poverty line, which includes most people who need supportive housing.  But 19 states have not expanded Medicaid, and in those states, only people with certain disabilities, seniors, or low- income families with children are eligible.  Barriers to proving disability status preclude many from Medicaid eligibility, especially homeless people with mental illness or substance use disorders.  Expanding Medicaid in the states that have not done so would be an important step toward providing supportive housing for more of those who need it.  Without expansion, other policy changes, such as those outlined below, will have a limited impact, since they will reach only a fraction of those who need supportive housing.
• Provide a broader range of Medicaid-funded services and supports, including services to help find and maintain housing.  States need to make changes to their Medicaid programs to better provide services for supportive housing.  Most health services available through Medicaid to help people stay in their homes are services that states are allowed but not required to offer, and many state Medicaid programs do not cover them.  The federal Centers for Medicare and Medicaid Services (CMS) recently described how Medicaid can provide services for supportive housing.^[52]  Medicaid can provide services such as personal care services in homes, behavioral health care services, intensive case management, and housing-specific supports like help searching for housing and working with landlords, if these services are necessary for someone to maintain their health and keep them out of expensive institutional care.  More states should take advantage of the flexibility they have to provide these services.
• Institute a process for supportive housing providers to secure Medicaid reimbursement where appropriate.  Most supportive housing providers have not traditionally billed Medicaid for various services that are eligible for Medicaid reimbursement.  States and managed care organizations should provide training and outreach to encourage supportive housing providers to bill Medicaid where that is appropriate.  This would help ensure that Medicaid-funded supportive housing services are provided mainly by organizations with supportive housing experience.
• Deliver support services in a more coordinated fashion.  Medicaid services are not always delivered in a way that fits the supportive housing model.  Services are often delivered only within the confines of an office, without coordination among providers.  Moreover, providers may not focus on preventing emergency room visits or other unnecessary treatment.  States could institute reforms in their health care systems to give hospitals, community health centers, and other providers incentives to provide the mobile, team-based services required for supportive housing, and focus on providing more appropriate care.  To achieve reforms, states can apply for waivers to some Medicaid rules and amend their Medicaid state plans.^[53]
• Use managed care more effectively.  Increasingly, states are relying on managed care organizations (MCOs) to provide and coordinate health benefits for Medicaid beneficiaries.  MCOs receive a set payment from the state per enrollee and are required to provide all needed services to their members, based on their contract with the state.  In addition to the services they are contractually required to provide, MCOs have some flexibility to provide mobile, flexible services and have helped some states provide supportive housing services.  States can require MCOs to provide supportive housing services to those who need them, and MCOs can work with supportive housing providers to make sure their members receive the right level of care.

If more states took these steps, more Medicaid services could be used in place of the services provided through limited grant dollars, freeing up those scarce resources to fill other needs.  States that increase Medicaid services for supportive housing should also consider reinvesting some of the potential health care savings to provide additional rental assistance.

Targeting Supportive Housing on Those Who Need It

Many people, even those with disabilities, are able to remain stably housed without supportive housing’s intensive services.  To best use available resources, supportive housing providers should ensure they admit only those who cannot succeed with a lower level of care.  In addition, a system should be in place to move people who no longer need supportive housing into lower levels of support.

There is currently no single standardized assessment that differentiates between people who need supportive housing and those who do not.   Providers often create their own assessments to target supportive housing on people who have been homeless for long periods of time, have multiple disabilities, have failed to remain healthy or stably housed with other treatments, or use health care and corrections frequently.

Yet no measure is perfect, and people will differ significantly in how long they need supportive housing.  So supportive housing providers must also have a process to move people to less intensive supports, though they likely will continue to need long-term rental assistance to afford housing in the community.  Such a “moving-on” system is relatively simple in supportive housing that links tenant-based rental assistance with community-based service providers.  These service providers, some of whom receive Medicaid reimbursement for their services, can serve anyone regardless of where they live and can adjust to provide a lower level of care. 

Supportive housing that is provided through project-based rental assistance needs more coordination to allow people to move out while retaining their rental assistance.  The building may be configured specifically to provide certain services (like having a clinic or therapist’s office on site), and someone remaining there who no longer needs a high level of support would prevent someone else from receiving it.  Housing Choice Vouchers are especially helpful in this situation, since people in units with project-based vouchers are allowed to move out with an available tenant-based voucher.^[54]  Other forms of project-based assistance do not have this option, but providers can work with their local or state public housing agency to target some tenant-based Housing Choice Vouchers for former supportive housing tenants to create a similar system.

Appendix: Federal Resources for Supportive Housing