Session: Community Integration and Its Determinants: Social Work Research at the Intersection of Behavioral Health and Housing Instability (Society for Social Work and Research 31st Annual Conference)

In the United States, the rapid increase in people experiencing housing instability or homelessness (PEHH) constitutes an urgent social problem. Behavioral health difficulties are diagnosed in higher rates among PEHH and can contribute to difficulties in maintaining stable housing in the context of stigma, discrimination, and ineffective social policies. This symposium explores the influence of housing instability on health risk behaviors and service utilization and examines low-barrier and community-based supports that promote community integration. The four presentations in this symposium offer a multidimensional view of the psychosocial and healthcare needs of PEHH, highlighting the unique barriers and facilitators to community integration that PEHH experience across the continuum of care.

The first paper leverages a national survey of adults entering opioid treatment services to examine the role of economic precarity, housing instability, and psychiatric distress on engaging in transactional sex. Clients with unstable housing had a threefold increase in the odds of past-year transactional sex, which can confer greater risk of exploitation and potentially adverse health outcomes. Findings underscore the relevance of integrated services to address substance misuse, sexual health risks, and unmet basic needs.

The second paper uses data from the Nationwide Emergency Department Sample to examine the independent association of housing instability and serious mental illness and substance use disorder on placement into long-term care (LTC) facilities. Unhoused patients living on the streets or in shelters were less like to be discharged to LTC relative to housed patients, although patients coded as having unstable housing had nearly 50% higher risk of long-term care placement. Housing status modified the relationship between inpatient length of stay and discharge to LTC. Findings suggest a potential misalignment between clinical need and access to post-acute care for unhoused patients.

The third paper investigates the potential benefits of a low-barrier drop-in center for unhoused adults served by a community mental health agency. Drawing upon 18 months of administrative data involving 310 unhoused clients, this study tests the association of engagement in a drop-in center with retention in clinical services. Drop-in center use was significantly associated with longer retention in services and enrollment into outpatient treatment services. Findings suggest the positive role drop-in centers can play in mitigating structural barriers to accessing services for PEHH.

The final paper closes the session with a qualitative study conducted with twenty-four formerly unhoused adults who presently utilize mental health and housing services to identify the skills and strategies that facilitated their transition to stable housing. Participants’ reflections on their diverse set of skills and resources, such as asking for help, communicating negative emotions, and reconnecting with loved ones, can inform efforts to tailor evidence-based interventions, such as social skills training, that facilitate attainment of recovery goals.

This symposium offers a critical realist framework for understanding the interplay of structural and personal dynamics that underlie community integration for PEHH and behavioral health conditions. Despite the various structural and social determinants that negatively influence community integration, findings underscore the need to implement low-barrier, recovery-oriented strategies for supporting community integration among PEHH.