Housing Boston's Chronically Homeless Unsheltered Population: 14 Years Later.

Objective: The long-term outcomes of permanent supportive housing for chronically unsheltered individuals, or rough sleepers, are largely unknown. We therefore assessed housing outcomes for a group of unsheltered individuals who were housed directly from the streets after living outside for decades.

Methods: Using an open-cohort design, 73 chronically unsheltered individuals were enrolled and housed in permanent supportive housing directly from the streets of Boston from 2005 to 2019. Through descriptive, regression, and survival analysis, we assessed housing retention, housing stability, and predictors of survival.

Results: Housing retention at ≥1 year was 82% yet fell to 36% at ≥5 years; corresponding Kaplan-Meier estimates for retention were 72% at ≥1, 42.5% at ≥5, and 37.5% at ≥10 years. Nearly half of the cohort (45%) died while housed. The co-occurrence of medical, psychiatric, and substance use disorder, or "trimorbidity," was common. Moves to a new apartment were also common; 38% were moved 45 times to avoid an eviction. Each subsequent housing relocation increased the risk of a tenant returning to homelessness. Three or more housing relocations substantially increased the risk of death.

Conclusions: Long-term outcomes for this permanent supportive housing program for chronically unsheltered individuals showed low housing retention and poor survival. Housing stability for this vulnerable population likely requires more robust and flexible and long-term medical and social supports.