Coordinating Housing in Substance Use Disorder Treatment: An Integrative Review

Background: For many individuals with a substance use disorder (SUD), homelessness is a concomitant condition that acts as a barrier to engaging in treatment (Manuel et al., 2017). Results from the National Survey on Drug Use and Health estimate that in 2017, 19.7 million people in the U.S. aged 12 and older had a SUD, of which 2.5 million were estimated to have received treatment (SAMHSA, 2018). The consequences of the prevalence of SUDs are numerous and include increasing numbers of overdose-related deaths and comorbid health conditions, and a tremendous economic burden related to health care expenses and loss of workforce productivity (Centers for Disease Control and Prevention (CDC), 2016; United Nations Office on Drugs and Crime, 2017; National Institute on Drug Abuse, 2017). Homelessness has also been identified as a national public health issue and has detrimental effects on mental and physical health (Donovan & Shinseki, 2013). For the one in five individuals who are experiencing homelessness and have a SUD, addressing both issues is key for recovery (Ashford, Brown, & Curtis, 2018). Studies and reports over the last 10 years have demonstrated the complex reciprocal relationship between homelessness, mental and physical health, and SUDs (Laudet, Stanick, & Sands, 2009; Henwood, Cabassa, Craig, & Padgett, 2013; Somers, Moniruzzaman, & Palepu, 2015). If available, housing in outpatient SUD treatment programs is often limited in amount and allowed length of stay (Manuel et al., 2017). Furthermore, missing in the literature is an understanding of best practices with respect to the process of coordinating housing for participants in these programs.

Purpose: The purpose of this review was to address the lack of consolidated information on key elements of the process for referral and coordination of housing services for individuals with a SUD who are experiencing homelessness. The question was “what are lessons learned and best practices for coordinating housing for participants in SUD treatment programs?”

Methods: An integrative review was focused on a comprehensive search of four databases – PubMed, CINAHL, The Cochrane Library, and Embase. The search terms used include housing, homelessness, homeless persons, mental health, and drug addiction, drug dependence, drug use disorders, substance dependence, substance abuse, substance addiction, and substance use disorders. No additional filters were used at the time of the initial search. Through this process, 1,562 records were identified. The references were screened and duplicates removed. The years of publication were limited to the past ten (2008-2018) and the records further reduced (n = 732). Articles were then assessed by title and abstract and included or excluded based on relation to the project problem. This resulted in 201 remaining articles, which were then assessed in their full-text version for explicit discussion of interventions related to coordination of housing services/referral to housing (as opposed to articles highlighting descriptive/demographic characteristics only). Articles that included descriptions or analyses of client experiences of intervention and implications for interventions were also included. The resulting articles (n = 8) were then retained for assessment of evidence quality based on the Johns Hopkins Nursing Evidence-Based Practice Model, and analysis for review (Dang & Dearholt, 2017). This process was documented using the PRISMA format.

Results: Eight articles were found to contain explicit descriptions of the process of housing coordination or referral (or key elements thereof). The selected articles were published between 2009 and 2017 and consist of one systematic review, two program evaluations, one meta-analysis, three qualitative studies, and one parallel randomized control trial (RCT). Using the Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines, each article was assessed for evidence level and quality rating. The levels of evidence ranged from I-V, and the quality of the articles was generally determined to be good (Quality B). The studies took place at a range of outpatient/residential substance use disorder programs and housing sites throughout the United States (the locations of the studies referenced in the systematic review were not identified). In reviewing the articles, four themes emerged in relation to key elements in the coordination of housing for participants of SUD treatment programs: housing as a primary element of SUD treatment, the need for improved collaboration amongst service providers, the importance of person-centered care, and improving discharge planning and referral systems. However, the small number of articles specifically focusing on the process of housing referral reveals the need for more research and discussion around best practices for program implementation.

Implications: The varied nature of both SUD treatment and housing programs and limited data about how they are implemented make definitive conclusions about best practices somewhat difficult to draw. However, the themes drawn from this sample of papers can be used to suggest considerations for current practice as well as directions for additional research. The negative effects of homelessness and the level of importance that both participants and staff place on obtaining stable housing underscore the importance of making housing stability a primary element of SUD treatment. Additional recommendations include increasing collaboration amongst service providers, implementing standardized patient assessments, and strengthening discharge planning processes in relation to housing. Ultimately, the limited number of sources is a call for further research into the methods of housing coordination, through which the accuracy of the themes identified in this review can also be further tested. Continuing research and development of best practices are necessary to improve the science and success of treatment for SUDs and reducing homelessness.