The cost-effectiveness of independent housing for the chronically mentally ill: do housing and neighborhood features matter?

Health Services Research, Oct, 2004 by Joseph Harkness, Sandra J. Newman, David Salkever

We use costs as the common metric to capture the broad range of hospital and community-based services (e.g., counseling, case management, partial hospitalization), and frequency of utilization (e.g., daily, half-day, hourly). Data on housing characteristics, neighborhood features and costs, including acquisition, rehabilitation, and operation, were collected as part of an earlier study of the costs of independent housing for the individuals with CMI (Harkness et al. 1997; Newman et al. 2001). These data were obtained from administrative records, interviews, and onsite observations of dwellings and neighborhoods.

OUTCOME MEASURES

Multivariate statistical methods are used to estimate the effects of features of the residential environment on community-based mental health service costs (CMTY), hospital-based mental health service costs (HOSP), and residential instability. Hospitalization and residential instability are two participant outcomes that have been relied upon in numerous studies as indicators of the mental health status of persons with severe mental illness (e.g., Bond et al. 1989; Hodgins, Cyr, and Gaston 1990). Furthermore, over roughly the last decade, research has suggested a relationship between inpatient hospitalization and quality of life. For example, Lehman, Possidente, and Hawker (1986) found that persons with serious mental illness who become rehospitalized report significantly lower quality of life along several dimensions including leisure activities, social relations, finances, and global satisfaction.

Other data collected in this study confirm that residential moves by participants were typically associated with negative results, supporting our use of residential instability as a relevant "negative" outcome indicator. Of those who moved out, many were evicted for nonpayment of rent, disruptive or destructive behavior, or substance abuse problems. Others moved because they were unable to cope with independent living and were transferred to a more structured environment, such as a residential treatment facility or hospital.

Building attributes that promote better mental health may impact community-based treatment costs in a variety of ways. To the extent that these features reduce institutionalization and increase time spent in the community, they will increase community-based costs (e.g., rehabilitation services, individual and group therapy, case management). On the other hand, a positive impact on mental health may also translate into lower community-based costs if building features reduce the need for high-intensity services (e.g., partial hospitalization) to deal with acute flare-ups, or reduce the frequency of on-going services (e.g., reduce therapy visits from weekly to biweekly).

Explanatory Variables

All models estimated outcomes as a function of demographic characteristics (race, age, sex), initial functioning level (as measured by the GAF score), building and neighborhood features, characteristics of other CMI tenants living in the same building, and supplementary control variables (site, missing data indicators, and time in study).