Experimental Trial of an Employment-Based Housing Program for Adults at Risk of Homelessness - Employment-Based Housing (EBH) is a novel model that helps unstably housed individuals obtain housing and on-site employment where they are housed. The long-term goal of this project is to examine how housing and vocational services can be integrated into hospital emergency departments (EDs) as a multi-sectoral intervention. Our central hypothesis is that EBH provides housing, employment, and health insurance which will reduce acute care use and ameliorate non-medical determinants of health more than standard care models. The rationale is that EBH addresses multiple upstream factors that can prevent recurring use of acute care, and the combination of housing with employment services will have positive synergistic effects. This project has three specific aims: 1) Conduct a three-arm randomized clinical trial comparing EBH to passive (resource list) and active control interventions (basic vocational services) on acute care use as the primary outcome and secondary outcomes related to housing, employment, and health-related quality of life; 2) Understand the experiences of different groups of participants including the large number of Hispanic and other participants in receiving EBH given possible linguistic and other considerations (e.g., multigenerational households) to implementation and the successful adoption of EBH that may require future program modifications/considerations; and 3) Identify barriers and facilitators to adoption of EBH in public healthcare systems in 11 other cities nationally. To achieve these aims, an EBH program will be integrated into the ED of the largest safety net hospital system in Houston, Texas- the 4th largest city in the United States. The project will include a three-arm randomized trial enrolling 750 participants (250 participants per arm). The three-arm trial allows for the investigation of the unique contribution of housing over other non-medical determinants of health (employment and insurance). Participants will be randomized to one of the three arms and followed for 12 months with assessments at baseline, 1, 3, 6, 9, and 12 months with evaluation surveys in months 2, 5, and 7. Qualitative data will also be collected through interviews with 24 participants and 11 focus groups with organizational stakeholders to identify individual-level and organizational-specific factors to inform potential scaling of the intervention. This project is innovative because EBH goes beyond traditional supported housing and supported employment models by seeking to address multiple determinants of health together, and may be more self-sustaining by promoting client independence and private-sector investment without the long-term uncertainty of governmental assistance. The proposed research is significant because EBH may help prevent both homelessness and unemployment and can fill gaps in the continuity of care between EDs and community-based services. Ultimately, the project will help inform practitioners and researchers on the clinical value of providing housing and vocational support services together for high-need populations.
