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SHan and SandlerAddressing the Homelessness Crisis in New York 
City: Increasing Accessibility for Persons With Severe 
and Persistent Mental Illness

LeeAnn Shan and Matt Sandler

Homelessness continues to be a persistent and highly visible public health issue 
in New York City. New York/New York III, the current initiative that aims 
to expand supportive housing services for New York City’s chronically homeless 
mentally ill population, will expire in June 2016. In the context of  shifting policies 
reflecting the growing popularity of  the Housing First model, the authors of  this 
paper call attention to the unique needs of  the severely and persistently mentally 
ill (SPMI) homeless population. The authors propose that the current and 
future states of  homelessness initiatives are inadequate in their levels of  funding, 
coordination, and regulation, thereby negatively affecting New York City’s most 
vulnerable residents. Drawing on evidence from the literature, we compare the 
Housing First and traditional housing readiness models in New York City, the 
latter of  which has become increasingly controversial in recent years. The authors 
provide suggestions for bridging the current gaps in research, policy, and practice 
in hopes of  increasing accessibility and prioritizing housing for this population.

Homelessness continues to be a persistent and highly visible public health 
issue in New York City. In 2013, the number of  people sleeping in 

city shelters each night reached its highest level since the Great Depression, 
with homeless families and children making up 78% of  this population 
(Markee, 2013). Approximately one-third of  all homeless individuals suffer 
from at least one serious mental illness, and 50% to 70% of  homeless 
mentally ill individuals also suffer from concurrent substance use disorders 
(Groton, 2013). Homeless shelters are projected to cost New York City 
close to $1 billion in 2015, a 62% increase in the last eight years (Bekiempis, 
2015).  These numbers reflect a serious problem in current service delivery 
and homelessness prevention methods.

New York/New York III, the current initiative that aims to expand 
supportive housing services for New York City’s chronically homeless 
mentally ill population, will expire in June 2016. On January 13th, 2016, 
Governor Andrew Cuomo issued a new initiative to create 20,000 new 
supportive housing units in New York State over the next 15 years. This 
initiative adds to Mayor Bill de Blasio’s prior commitment to fund 15,000 
units in the city over the same time period (Rought, 2016). In the context 

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© 2016 Shan and Sandler. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited.

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50 | Columbia SoCial Work revieW, vol. vii Columbia SoCial Work revieW, vol. vii | 51 

SHan and Sandler

of  these new developments and shifting policies reflecting the growing 
popularity of  the Housing First model, the authors of  this paper call 
attention to the unique needs of  the severely and persistently mentally ill 
(SPMI) homeless population. The authors propose that the current and 
future states of  homelessness initiatives are inadequate in their levels of  
funding, coordination, and regulation, thereby negatively affecting New York 
City’s most vulnerable residents. Drawing on evidence from the literature, we 
compare the Housing First and traditional housing readiness models in New 
York City, the latter of  which has become increasingly controversial in recent 
years. In doing so, the authors provide suggestions for bridging the current 
gaps in research, policy, and practice in hopes of  increasing accessibility and 
prioritizing housing for this population.

A Brief History
Modern homelessness in New York City has roots in two important 

historic events: the deinstitutionalization movement and the decline of  
the single-resident occupancy housing market (Baxter & Hopper, 1982; 
cite: Coalition for the Homeless). The deinstitutionalization movement, 
which began in New York State in the 1950s, facilitated the discharge of  
thousands of  psychiatric patients from state hospitals and other inpatient 
facilities into the general community. This policy stemmed from new 
psychopharmacological developments and studies advocating for less 
restrictive, community-integrated approaches to treatment (Durham, 1989; 
Talbott, 2004).  Over the next few decades, negative public opinion toward 
inpatient treatment strengthened the movement, largely shaped by popular 
media depicting abhorrent hospital conditions (e.g., the 1962 novel One Flew 
Over the Cuckoo’s Nest).

As a result of  deinstitutionalization, the number of  resident patients 
in New York State psychiatric centers fell by 68% between 1965 and 1979 
(Coalition for the Homeless, 2015). Lack of  follow-up services meant that 
many newly released individuals were left without any treatment or community 
support. With limited resources and inadequate follow-up services, the patients 
sought housing in low-cost, single-resident occupancy (SRO) units. During 
this era, from 1955 to 1975, restrictive zoning ordinances and changes in 
New York City housing regulations essentially prevented the creation of  any 
new SROs (Dennis et al., 1991). In addition, gentrification and property tax 
policies financially incentivized owners of  existing SRO buildings to convert 
SRO units into higher-priced rental housing, cooperatives, or condominiums 
(Coalition for the Homeless, 2015). These events led to a rapid decline in the 



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addreSSing THe HomeleSSneSS CriSiS in neW york CiTy SHan and Sandler

SRO housing stock, which continued for several decades and severely limited 
both access to and availability of  housing.

Adverse political, economic, and social contexts perpetuated modern 
homelessness. For individuals who struggle with mental illness, the impact of  
homelessness is especially consequential. Compared with their non-mentally 
ill counterparts, such individuals generally remain homeless for longer periods 
of  time, have fewer social supports, poorer health outcomes, and experience 
more barriers to employment (Tessler & Dennis, 1989). Homelessness 
impedes continuity of  care, which further exacerbates these problems.

Past supportive housing plans in New York were a response to the 
ubiquity of  conspicuous homelessness on city streets. The origins of  city 
and state coordination on supportive housing date back to 1990, when 
Mayor David Dinkins and Governor Mario Cuomo entered an agreement 
called New York/New York to create 5,000 supportive housing units for 
chronically homeless New Yorkers. The agreement has since been renewed 
twice, first in 1999, when 2,000 units were added [New York/New York II], 
and again in 2005, when the city and state agreed to create 9,000 units over a 
10-year period through the New York/New York III initiative (Office of  the 
Public Advocate, 2015). 

Housing First
As a way of  tackling homelessness for this most vulnerable and chronic 

mentally ill population, Sam Tsemberis, the founder of  the New York-based 
organization Pathways to Housing created the Housing First model in 1992 
(Tsemberis & Asmussen, 1999). The model’s philosophy states that access 
to housing integrated with appropriate and ongoing support services is of  
immediate concern and should not be contingent on commitment to mental 
health and/or substance abuse treatment. Housing First aims for harm 
reduction, in contrast to a housing readiness approach, which emphasizes 
that psychiatric treatment and/or sobriety should be a precondition to stable 
housing (Tsemberis, Gulcur, & Nakae, 2004).

Evidence of  Housing First’s effectiveness has been demonstrated in 
multiple research studies, set within a variety of  contexts (Goering et al., 2011; 
Tsai, Mares, & Rosenheck, 2010; Stefancic et al., 2013; Stefancic & Tsemberis, 
2007). It is important to note, however, that most studies investigating the 
effectiveness of  the Housing First model have had a strong research affiliation 
with the agencies being evaluated (Groton, 2013). Thus, it is possible that this 
bias could have influenced more favorable study outcomes.

In a 5-year longitudinal study, Tsemberis and Eisenberg (2000) compared 



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housing retention rates among New York City individuals housed through 
the Pathways to Housing program with those who were housed through 
standard care, treatment-first programs. As predicted, Housing First tenants 
maintained significantly better housing tenure over the duration of  the 
study—88% remained housed, compared with 47% of  the control group 
(Tsemberis & Eisenberg, 2000). Housing stability has also been linked to 
positive health outcomes for individuals with mental illness, as evidenced by 
lower rates of  hospital utilization (Kyle & Dunn, 2008), and improvements in 
overall neuropsychological functioning (Seidman et al., 2003).

In addition to individual benefits, the Housing First approach also 
promises improvements on a macro scale. In terms of  cost effectiveness, 
increased access to permanent housing and services means decreased risk of  
contact with the criminal justice system and lowered use of  costly acute care 
services such as emergency shelters and hospital emergency rooms (Dennis 
et al., 1991; Gulcur, Stefancic, Shinn, Tsemberis, & Fisher, 2003).  In a 2013 
randomized controlled trial on five major Canadian cities that adopted the 
Housing First program, it was found that the approach was both effective in 
reducing homelessness and economic impact—“government savings were 
even greater for those who used services the most, with three dollars saved 
for every two dollars spent” (Tsemberis & Stergiopoulos, 2013, p.1). 

Continuum of Care
The Continuum of  Care was first implemented by the United States 

Department of  Housing and Urban Development (HUD) in 1995 and 
prescribed a housing readiness model (O’Connell, 2003). Unlike the Housing 
First approach, the housing readiness approach used in the Continuum of  
Care system centered on the idea that homeless individuals, including those 
diagnosed with mental illness, must pass through a series of  temporary 
residential programs (e.g., emergency shelters, transitional housing) with 
varying levels of  care prior to attaining permanent, independent housing 
(Gulcur et al., 2003). As a result, HUD allocated funding to those housing 
organizations that followed such a model. For the subset of  SPMI individuals 
who may not be equipped to care for themselves in an independent setting, 
the requirements of  this kind of  graduated model—which often include 
psychiatric medication compliance, participation in psychotherapy, and/or 
psychosocial rehabilitation—offer the structure and support not necessarily 
emphasized in Housing First programs. 

Although the majority of  SPMI adults report a preference for living 
in as independent and normative a setting as possible (Yamada, Korman, 



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& Hughes, 2000), and consumers that live under these conditions report 
higher levels of  satisfaction (Wilson, 1992), it is important to remember 
that subjective satisfaction alone does not eliminate the risk of  returning to 
homelessness. In fact, Yamada and colleagues (2000) found that consumers 
who were placed in group homes or supported housing with “appropriate 
structure and support” (p. 36) were able to remain in the community for 
twice as long as those living independently.

Consumer self-determination is a key component of  the Housing First 
Model that should not be negated. However, social isolation—a significant 
predictor of  psychiatric relapse (Hultman, Wieselgren, & Öhman, 1997)—
continues to be a reality for SPMI adults, as community integration can 
prove extremely challenging. Individuals with severe mental illness living in 
independent housing report significantly more social isolation than those living 
in group settings or supportive housing with on-site visits by staff  (Friedrich 
et al., 1999). For these reasons, the New York/New York supportive housing 
agreements successfully created different levels of  supportive housing to 
include custodial and therapeutic services to meet the variety of  needs for 
chronically homeless individuals and families. In addition, ensuring housing 
in beneficial neighborhoods with well-maintained buildings has been linked 
to lower costs of  mental health services for SPMI adults (Harkness et al., 
2004).

Housing First has evolved to satisfy these unique needs of  the populations 
it serves through different levels of  supportive housing. In 2013, HUD 
changed its Continuum of  Care guidelines 
and began prioritizing funding for localities 
whose service providers use the Housing First 
model (U.S. Department of  Housing and 
Urban Development, n.d.) to address chronic 
homelessness. This change in policy is a major 
step forward in recognizing the efficacy of  
providing housing stability as the cornerstone 
to successful treatment for SPMI and other 
chronically homeless populations. This 
prioritization, though, while supported by many service providers, also came 
with unintended consequences. Service providers in New York City provide 
mostly transitional housing services in the form of  emergency shelter. Given 
the number of  homeless in the city, shelter remains an important safety net. 
Under the new Continuum of  Care guidelines that prioritize Housing First, 

“This change in policy is 
a major step forward in 

recognizing the efficacy of 
providing housing stability 
as the cornerstone to 
successful treatment for 
SPMI and other chronically 
homeless populations.”



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service providers that run shelters stand to lose some HUD funding. 

New York/New York IV: A Lost Opportunity
The lost funding opportunities and increased number of  homeless 

individuals in shelters and on the street made an updated New York/New 
York supportive housing agreement even more crucial. What should have 
been a matter of  course—an agreement between city and state to fund a new 
crop of  supportive housing units—turned into a political tug-of-war between 
Mayor de Blasio and Governor Cuomo over cost sharing.

Under previous New York/New York supportive housing agreements, 
the state paid 50% of  capital expenses while covering 80% of  service costs 
(Stewart, 2015). The mayor began negotiating an agreement by seeking 
12,000 units in New York City. The governor responded by offering 3,900 
units and changing the previous funding scheme from the state covering 80% 
of  service costs to an even 50-50 split (see: Editorial Board). The impasse 
resulted in the mayor and governor each announcing his own independent 
plan for creating more supportive housing; New York City will create 15,000 
units of  supportive housing over the next 15 years, and the State will create 
20,000 units in the same time. On a positive note, the political spat resulted 
in a one-upmanship that created more supportive housing than either city or 
state initially offered.

The independent announcements from the mayoral and gubernatorial 
administrations demonstrate a significant increase in resource allocation to 
supportive housing. However, these plans function independently of  one 
another and are not a coordinated New York/New York IV agreement. 
This is significant, as the independent initiatives abandon the efficiency of  
previous coordinated efforts between the city and state. Past agreements 
allocated resources and processes for capital financing and service delivery 
in concert. Now, with two separate initiatives, nonprofits charged with 
creating new units of  supportive housing will likely encounter administrative 
hassles. A new coordinated New York/New York agreement would be a 
more efficient strategy to reduce chronic homelessness, as well as a more 
financially responsible approach. The New York City Department of  Health 
and Mental Hygiene estimated in 2013 that the New York/New York 
agreements resulted in public savings of  $10,100 annually per unit (Coalition 
for the Homeless, 2015) through decreased use of  emergency services.

Conclusion
Supportive housing is appropriate for the chronically homeless and makes 



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financial sense for the city and state because of  the high cost of  care otherwise 
associated with individuals and families who use emergency services at a high 
rate. It is important, though, to consider that the chronically homeless are a 
subpopulation of  a larger whole. Nearly one-third of  individuals and heads 
of  household in the New York City Shelter system have earned income 
(Iverac, 2015), and would not qualify for supportive housing. The city and 
state can partner to make rental subsidies, such as the Living in Communities 
(LINC) subsidy introduced in 2014, viable options for these individuals and 
families. The two can also work together to help prevent homelessness by 
working together to increase funding for the Solutions to End Homelessness 
Program (STEHP).

These issues must be tackled in a partnership between the city and state, 
and this requires a coordinated effort between the mayor and governor. 
Although it is encouraging that more supportive housing will be created 
over the next 15 years, it is disappointing that these units could not build 
upon the legacy of  a New York/New 
York agreement.  The success of  Housing 
First supportive housing under the banner 
of  a New York/New York IV housing 
agreement could be monumental. A robust 
housing plan to curb chronic homelessness 
in the country’s largest city would certainly be a notable achievement. A plan 
of  this nature would signal the joint commitment to providing stability and 
services to the vulnerable subpopulation of  SPMI individuals and families. In 
the meantime, we welcome the independent plans and look forward the city 
and state’s commitments to addressing chronic homelessness.

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“These issues must be tackled 
in a partnership between the 

city and state, and this requires 
a coordinated effort between 
the mayor and governor.”



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LeeAnn Shan is currently a second-year student at CUSSW and Executive Editor 
for the Columbia Social Work Review. She is concentrating in Advanced Clinical 
Practice, with a focus on Health, Mental Health, and Disabilities. She is currently 
placed at New York State Psychiatric Institute, where she works on the inpatient 
research unit with adults with severe mental illness. LeeAnn is also a research assistant 
at Columbia’s Experimental Psychopathology Laboratory, where she studies the 
treatment and prevention of  schizophrenia and schizophrenia-spectrum disorders. 
LeeAnn plans to apply to Ph.D programs after graduation, so she can continue to 
pursue research into these topics.

Matt Sandler is a senior editor at the Columbia Social Work Review and an MS 
candidate in his second year at the Columbia School of  Social Work. His Field of  
Practice is in Public Policy, with an academic concentration on contemporary social 
issues related to poverty. Matt has worked extensively in homeless services, directly 
with clients, and in coalitions with providers.




