Rethinking Permanence In Housing First: Evidence on Permanent Supportive Housing Exit Outcomes

Background and Purpose:
Housing First (HF) is an evidence-based approach to ending homelessness that prioritizes immediate access to permanent housing without preconditions. While the “permanent” nature of housing is a core tenet of HF, growing system pressures—particularly limited supply of permanent supportive housing (PSH)—have prompted interest in how, for whom, and under what conditions individuals may successfully transition to lower levels of care. This study contributes to a broader symposium examining adaptations of HF by interrogating the role of permanence in HF PSH. Specifically, we examine whether and how transition from PSH aligns with HF principles and what these transitions reveal about the meaning and function of permanence within the HF model.

Methods:
This observational study uses a two-state, population-level dataset linking Homeless Management Information System (HMIS), Medicaid claims, and housing data from New Jersey and Pennsylvania (2016–2021). The sample includes Medicaid-enrolled adults in PSH. Exit destinations were categorized by level of care, with “successful exits” defined as transitions to permanent housing without ongoing supportive services. Analyses include pooled cross-sectional regression models to identify individual-, program-, and community-level predictors of exit type, and cohort analyses to assess post-exit housing stability and healthcare utilization. Models adjust for demographic, clinical, programmatic, and geographic factors.

Results:
Findings indicate that while PSH is largely non-transitional, successful exits do occur. Approximately 60% of participants did not exit PSH during the study period; ~12.5% exited to successful destinations and ~8% to unsuccessful destinations. Among those exiting successfully, returns to homelessness were relatively rare (~10% within 24 months), and healthcare utilization patterns were generally stable or improved. Successful exits were associated with younger age, female gender, absence of substance use disorder, longer lengths of stay, and residence in more affordable housing markets. However, structural constraints were salient: affordable housing availability was a key predictor of successful exit, and program and geographic factors also shaped outcomes. Notably, Black and Hispanic participants were more likely to exit successfully but also more likely to return to homelessness, raising important equity considerations.

Conclusions and Implications:
These findings suggest that, while HF PSH is appropriately designed as a non-time-limited intervention, PSH can also function as a platform from which some individuals may pursue voluntary transitions. The evidence that successful exits are possible—and often associated with stable housing and comparable or improved healthcare utilization—points to opportunities for HF PSH programs to more intentionally support transitional pathways when aligned with tenant goals. Promoting positive exits requires shifting from a passive model of permanence to an active, tenant-centered approach that includes regular assessment of transition preferences, pursuit of affordable housing resources, and support navigating the private housing market. At the same time, the rarity of exits and the finding on housing affordability underscore that these pathways are contingent on structural conditions, not simply individual readiness. Within the context of broader HF adaptations these findings highlight the importance of conceptualizing HF PSH not as the final stop in homeless services, but as a stepping stone to greater independence.