A Randomized Controlled Trial on Permanent Supportive Housing for Individuals Exiting Prison

2023-05-01

2025-11-01

The initial goal of the program is to reduce the incidence of homelessness of exiting prisoners. Our first primary outcome is then whether the program improved this outcome. We plan to track homelessness through Homeless Management Information Systems (HMIS) in relevant locations. This data will allow us to capture participants’ use of housing services. We also plan to track housing stability measured by frequency of moves using the consumer reference database Infutor.

Homelessness is thought to be a precursor for future criminal involvement, so our other primary outcome is criminal recidivism (e.g., arrest, imprisonment, length of time incarcerated) within 1, 2, and 3 years after randomization. We will use the state’s Department of Corrections data to measure criminal justice outcomes.

Secondary outcomes capture participant wellbeing through health, employment, and earnings.

For health outcomes we plan to use state Medicaid data. The state where the experiment will occur is a Medicaid expansion state and most released prisoners will then be eligible for Medicaid. Outcomes here will include emergency department visits and inpatient hospital stays.

Employment and income data will be obtained through state unemployment insurance data. These state records provide quarterly values of earnings in the sectors covered by unemployment insurance. Outcomes will include earnings from all jobs in the quarter and a dummy variable that measures whether a person worked in the quarter. This data does not have hours of work.

Our ability to track these outcomes will be contingent upon securing data sharing agreements with relevant partners.

CSH accepts applications for placement in their PSH program on a rolling basis. While individuals are incarcerated, linkage workers, who are employed by Ohio’s Department of Mental Health and Addiction Services (OMHAS), will identify those who may be a good fit for one or both of the PSH programs. For the Community Transition Program (CTP), this means that the individuals will have participated in recovery services while incarcerated, and for Returning Home Ohio (RHO), this means that they will be diagnosed with a serious and persistent mental illness or be HIV positive. Linkage workers will conduct JD-VI-SPDAT assessments (which assess vulnerability and identify housing needs) and complete program applications for eligible individuals interested in participating in the program. Many individuals who are eligible for one program will also be eligible for the other.

The intake process will include a study consent form explaining the purpose of the research, the randomization process, and what personal information will be shared with the research team for those consenting to participate in the research study. Potential study participants will go through the consent process with a linkage worker, who will be able to answer questions. Consent to participate in the study will not affect the likelihood of being offered a spot. As there are many more exiting prisoners eligible for the programs than available slots, all slots will be offered via a lottery.

All individuals who are referred to either program, regardless of whether they consent to participate in the study, will be placed on CSH’s master waitlist. Eligible formerly incarcerated individuals released without having been screened for the programs can be referred to CSH by community partners within 120 days of release and added to the master waitlist.

Once per month, CSH meets with the local housing agencies who implement the programs. During these meetings, they identify the number of placements that are available in each location and any restrictions associated with those placements. For example, if an agency does not accept people with an arson or sex offense. After the specific placements have been identified, CSH will identify the individuals most recently added to the waitlist who qualify for each placement. They will attempt to contact these individuals one at a time to ascertain their continued interest in the program. Past experience shows that many people will not have working cell phone numbers or email accounts so they will be removed from the waitlist after three attempts to contact. For every available PSH slot, the CSH associate program manager will identify a set of four eligible participants that are still interested in the program. From this list, they will randomly select one person to be referred to each spot using a randomization tool that LEO has designed. Although we plan on a 3:1 ratio of controls to treatment, this will be a function of demand at the local level and some agencies may have lower levels of control to treatment ratios.

Individuals who are placed in the treatment group will be referred to the relevant housing agency, which will assist them in their housing search and attempt to place them in suitable housing. When their housing is secured, the individual will be able to use the PSH voucher the housing agency provides. Once placed in housing, the individual will be added to an intensive case management system (i.e.., the “supportive” component of PSH) and introduced to opportunities to access mental health treatment, workforce development, childcare, and healthcare. The housing agencies connect their clients to housing and supportive services. They do not directly house participants themselves. Participants who are placed in the control group will be given information on other services in the community that could be beneficial to them.

Not available

Computer random number generator

Individual

No

N/A

880

e anticipate 275 individuals to be randomized to Treatment and 825 individuals to Control. With an assumed 80% rate of consent to participation in research, our analysis sample would include 220 individuals in Treatment and 660 in Control. The exact number and ratios will depend upon the fraction of applicants who consent to participate in the research and the size of the waitlist relative to the number of open spots for each county-specific program each month.

Our power calculations assume a set of controls with an R-squared of 0.10, and a randomization ratio of 1 person in the treatment group for 3 people in the control group. With these inputs, our target sample size for the study is 880 consenting participants, which we expect to reach in about 2.5 years of enrollment. For homelessness, we turn to prior research to guide our power calculations. We estimate that given our sample size and research design, we will be able to detect a 17 day reduction in homeless shelter days over 3 years, coming from a baseline of 269 days. This estimate assumes a normal distribution of outcomes and is based on a control group mean from Cunningham et al. (2021), which found a reduction of 96 shelter stay days over 3 years for the treated group. For recidivism as an outcome, we rely on historical data from CSH. CSH projects that those in the target population who do not enroll in RHO or CTP have a recidivism rate of approximately 30 percent within three years, and that those who do enroll in RHO or CTP have a recidivism rate of 7 percent within the same time frame, a 23 percentage-point drop. The study is powered to obtain a more conservative minimum detectable effect (MDE) of an 8.5 percentage-point change in three-year recidivism for the treatment group compared to the control group, from a baseline of 30 percent. Given the estimated impact of a 23 percentage point reduction in 3-year recidivism, an 8.5 percentage point MDE (or a 12.1 percentage point MDE in terms of treatment-on-the treated, assuming a 70% take-up rate) gives us confidence we will be able to detect significant effects with our design and sample size. Separately, we find that we can detect a reduction of 0.7 arrests over 3 years, coming from a baseline of 10.6 arrests, assuming a normal distribution of outcomes. Cunningham et al. (2021) found a reduction of 4.3 arrests over 3 years for the treated group. This additional power calculation strengthens our confidence that we will be able to detect effects in key outcomes. One challenge with securing housing for housing insecure, recently incarcerated individuals is that they can be transient and challenging to contact. To ensure high take up of PSH among the treated group, all individuals will be contacted to confirm interest and eligibility just prior to their randomization in the study. Given these precautions, we conservatively estimate for our power calculations that 70 percent of those assigned to the treatment group will follow through with housing placement through CSH. In a prior RCT of frequently arrested, chronically homeless individuals, nearly 88 percent (285 out of 325) of the treatment group who were successfully contacted secured a lease through the supportive housing program (Cunningham et al., 2021). Reference: Cunningham, Mary K., Devlin Hanson, Sarah Gillespie, Michael Pergamit, Alyse D. Oneto, Patrick Spauster, Tracey O’Brien, Liz Sweitzer, and Christine Velez. (2021). Breaking the Homelessness-Jail Cycle with Housing First: Results from the Denver Supportive Housing Social Impact Bond Initiative. Urban Institute.

Pre-Analysis Plan: A Randomized Controlled Trial on Permanent Supportive Housing for Individuals Exiting Prison