Barriers and Facilitators to Resolving Older Adult Homelessness through Stays with Family

Abstract

Living with family and friends is a common strategy used to prevent or exit homelessness, but little is known about structural barriers that impede family and friends’ ability to provide temporary or permanent housing for older homeless adults. We conducted semi-structured interviews with 46 homeless participants from the HOPE HOME study, a cohort of 350 community-recruited homeless adults age 50 or older in Oakland, CA, who reported having stayed with housed family/friends for 1 or more nights in the prior 6 months. We conducted semi-structured interviews with 19 hosts of homeless participants and 11 stakeholders in housing and homelessness. We found that homeless older adults and hosts perceived staying with family or friends as a form of temporary housing rather than as a permanent exit to homelessness. Structural barriers to family and friends providing housing for temporary stays or permanent exits from homelessness included housing regulations restricting visitors and changing rent obligations; decreased eligibility and priority for shelter and permanent housing; geographic and transportation challenges; and environments inconducive to older adults. We suggest four areas for policy reform: providing subsidies to hosts and homeless individuals, removing disincentives for homeless older adults to stay with family, changing lease regulations, and expanding the supply of affordable housing.

Introduction

Each night in the United States, an estimated 568,000 adults experience homelessness (Henry et al., 2019). The homeless population is aging; this trend has continued beyond what would be expected by the aging of the general population (Culhane et al., 2013; Hahn et al., 2006). Homelessness has a deleterious effect on health (Fazel et al., 2014; Lee et al., 2010). Individuals experiencing homelessness have an earlier onset of age-related health conditions, chronic diseases, and cognitive or functional impairments, and a greater prevalence of chronic conditions (Brown et al., 2016b; Garibaldi et al., 2005).

Chronic homelessness is defined as homelessness lasting for a year or more, or four or more episodes in the prior three years amounting to a year or more, and having a disabling diagnosis (U.S. Department of Housing and Urban Development, 2015b). Subsidized housing with voluntary services, known as permanent supportive housing (PSH), is effective at maintaining housing stability for those who are chronically homeless (Aubry et al., 2015; Raven et al., 2020). The federal government endorses PSH as the preferred intervention for individuals experiencing chronic homelessness (National Academies of Sciences et al., 2018). However, many people either do not meet the eligibility criteria for PSH, do not need its services, or cannot access it due to the limited supply.

The majority of single adults who experience homelessness regain housing before becoming chronically homeless (Henry et al., 2019). However, adults who experience homelessness for the first time in older age are more likely to progress to chronic homelessness than those who first experienced homelessness in early adulthood (Cohen, 1999; Crane, 1996). Many individuals, including those experiencing chronic homelessness, self-resolve, or exit homelessness without the assistance of governmental programs, yet little is known about policies that promote or impede self-resolution.

To prevent or delay homelessness, many people live temporarily with family or friends (e.g. couch surfing, doubling up) (Shinn et al., 1991). Yet, little is known about how people who are homeless use these stays to exit homelessness (Bush & Shinn, 2017). Some localities pay for transportation back to families who agree to take in their homeless relative (Baker, 2019), but few offer support beyond transportation. Little research examines the practice of older homeless adults moving in or staying with family or friends and what policies might interfere with or promote this practice. Older adults experiencing homelessness may have unique challenges to temporary stays compared to younger adults, such as mobility issues and access to particular social services, and thus are important to study independently (Brown & Steinman, 2013; Hecht & Coyle, 2001).

To understand the phenomenon of moving in with family or friends as a strategy to shorten or end homelessness, we conducted a qualitative study in a purposive sample of older homeless adults, family and friends who host them, and stakeholders, such as policymakers, homeless service providers, and program administrators. We describe (1) structural barriers and facilitators to living with family and friends and (2) recommendations for policy, regulatory, and service delivery reforms to ameliorate these barriers.

Methods

Study Rationale and Design

The Family-Assisted Housing (FAH) Study is a qualitative sub-study of the larger Health Outcomes of People Experiencing Homelessness in Older Middle Age (HOPE HOME) study, a longitudinal cohort study of older adults experiencing homelessness (Brown et al., 2016a). The FAH study included in-depth, semi-structured qualitative interviews with 46 purposively sampled HOPE HOME participants who reported family stays in the prior six months; 19 hosts, family or friends who hosted one of the original FAH participants; and 11 stakeholders, individuals who work in homelessness, housing, or related policy fields. The FAH study used qualitative methodologies to understand the motivations for and consequences of short- and long-term stays with family and friends from the perspectives of older homeless adults and family members and friends who hosted them. Consistent with the social-ecological model, we explored the individual, relationship, community, and policy factors that contribute to motivations for short- and long-term stays, as well as their benefits and challenges.

Recruitment

We recruited HOPE HOME participants from overnight homeless shelters (n = 5), low-cost meal programs (n = 5), a recycling center, and locations where unsheltered homeless adults stayed using a sampling frame designed to approximate the homeless population in Oakland, CA by randomly selecting potential participants at each recruitment site (Lee et al., 2016). Study staff interviewed HOPE HOME participants at six-month intervals about health, social support, housing history, health-related behaviors, and health care utilization. We purposively sampled 46 HOPE HOME members who had stayed overnight with family or friends within the prior 6 months. To recruit hosts, we asked FAH older homeless adult participants to share the names of the family or friends with whom they stayed. Study staff contacted potential hosts and offered enrollment. We told both older homeless adults and potential hosts that we would not share any information they gave us with their paired family member. We recruited 19 family members and friends who hosted older homeless adult participants. To recruit stakeholders, we solicited HOPE HOME Community Advisory Board members to recommend stakeholders and used snowball sampling techniques to identify additional stakeholders. We recruited 11 stakeholders who worked for organizations that provide affordable housing or homeless services or who served in related policy roles. All participants completed informed consent procedures, and we provided older adults and hosts $25 for qualitative interviews and stakeholders $50 for each interview.

Data Collection

Researchers trained in qualitative data collection conducted interviews lasting 60–90 minutes. For older homeless adults, interviews examined participants’ experience of short- and long-term stays with family and friends, including motivations for and benefits and challenges of stays. Interviews with hosts examined their experience housing an older homeless adult relative or friend. Hosts were a diverse group of individuals in terms of their relationships with the older homeless adult participants who stayed with them temporarily, and included adult children, parents, siblings, aunts, former romantic partners, and long-term friends. We conducted participant and host interviews in private offices at a community-based nonprofit organization serving low-income adults or where participants lived. We conducted interviews with stakeholders lasting 30–60 minutes over the phone or in person. Stakeholder interviews examined experiences with policy and/or service provision. We audio-taped all interviews. A professional transcriptionist transcribed the recordings verbatim and deidentified participant information. The institutional review board of the University of California, San Francisco approved all study activities. We ceased interviewing when we reached thematic saturation.

Data Analysis

Consistent with grounded theory methodologies, we began data analysis simultaneous to data collection (Corbin & Strauss, 2015). We engaged in three interpretative activities: (1) data summarizing and consensus data analysis discussions, (2) codebook development and coding, and (3) data synthesis. First, we created detailed one-page summaries immediately after the completion of each qualitative interview. These summaries included the basic outline of content participants’ described in the interviews as well as theoretical memoing, in which interviews offer thematic impressions and insights (Glaser, 1998; Montgomery & Bailey, 2007). The data analysis team discussed all of the transcripts and accompanying summaries then developed the preliminary codebook for the older homeless adult participant data set in a final data analysis consensus meeting.

Two coders independently coded five interviews and then met with a study investigator to revise code definitions, delete or collapse codes, and add new codes. We revised the codebook three additional times until no further changes were necessary. We deployed the same analytical process for developing the host and stakeholder codebooks, adding dataset-specific codes to the participant codebook. We entered coded transcript data for all three data sets into the Atlas.ti Qualitative Data Analysis Software (ATLAS.ti Scientific Software Development, 2017). Finally, we engaged in consensus discussions with the analytic team about the findings. We identified salient themes emergent in the consensus discussion and data coding processes, with an emphasis on themes’ scope, inter-relationship, and relevance to current literature on older homeless adults and their familial and social networks.

For this analysis, the first author (CC) reread transcripts from all three data sets, conducted searches of specific codes in Atlas.ti and completed theoretical memos to identify policy, programmatic, and service delivery challenges to and opportunities for housing older adults with family members or friends (Montgomery & Bailey, 2007; Sandelowski & Leeman, 2012). We triangulated the qualitative findings across the three study data sets by examining which themes diverged and converged across the three samples. This process increased our understanding of the policy and programmatic consequences of short- and long-term stays with family and friends. We suggest policy and service provision solutions that might mitigate these challenges.

Theoretical Approach

The social-ecological model (SEM) argues for a research approach that responds to the multifactorial nature of homelessness, by addressing the influences of individual, relationship, community, and policy factors, and analyzing how these factors intersect (Stokols, 1996). Others have adapted SEM to address complex social problems in the adult population, underscoring its appropriate application for the study of homelessness, family relations, and the experiences of living together temporarily (Bowen, 2016; Chatterjee et al., 2018).

During data collection, individual factors for homeless participants and their hosts included personal and behavioral factors that facilitated or impeded the ability to live with one another. Relationship factors described interpersonal factors between homeless individuals and their family members that may promote or impede living together (Handley et al., 2020). Community factors are larger environmental, social, geographic, and resource issues. Policy factors encompass the domain of local, state, and federal laws and regulations (Handley et al., 2020). In this study, we gave participants in each group (older adults experiencing homelessness, family/friend hosts, and stakeholders) the opportunity to address any of the domains during interviews. This analysis is focused on research findings in the domains of community and policy factors. We have reported results addressing individual and relationship factors that influence motivations, barriers and facilitators to temporary stays with family and friends among older homeless adults elsewhere (Knight et al., 2021; Rosenwohl-Mack et al., 2019)

Results

Demographic Information

Among the 46 study participants who reported staying with housed family members for a day or longer in the prior 6 months, 87% were Black, 11% were White, and 2% were Latinx. Three quarters were men. Almost half, 45%, first became homeless at or after the age of 50. The mean age of older homeless adults was 58 years. Among 19 host participants, 14 were women and 4 men; 17 were Black and 1 was White. We did not collect age data on hosts. We did not collect demographic data on study stakeholders.

Brief Characterization of Temporary Stays

Most older homeless adults considered living with family/friends as a temporary, not permanent, housing arrangement. They saw these stays as a respite from the experience of homelessness that offered mutual emotional and financial benefits. Interpersonal relationships between older homeless adults and their hosts were characterized by desires for mutual caregiving and support and challenged by conflicts related to substance use and experiences of intergenerational trauma (Handley et al., 2020; Rosenwohl-Mack et al., 2019).

Older homeless adults and hosts characterized stays with family and friends as a temporizing measure, akin (and in many cases preferable to) emergency shelter, rather than as permanent housing. One older homeless adult stated that he could rely on his host to provide shelter during the winter: “But I know when summer time come, I’m out. And I can accept that. I know it’s temporary.” One stakeholder stated that living with family would work as a form of temporary shelter but would “never…work as a long-term solution.” Nearly all older homeless adults in the study expressed the desire to have their own place to live: safe, private, and uncrowded housing in which they could retain financial and personal independence.

Policy and Community-level Challenges

Restrictive Housing Regulations and Rent Burden

Hosts stated that stipulations on their lease or regulations that governed rental housing were barriers to hosting an older homeless adult. Hosts living in subsidized housing generally had leases that limited guest visits to 21 days a year (or 14 consecutive days), and many in non-subsidized housing described similar restrictions. Some hosts were willing to house older adults for longer despite guest restrictions, but both hosts and older homeless adults expressed concern about risking eviction by violating these regulations. Some of these hosts are put in a precarious position when landlords were lenient about the stays.

I’ve had my family members that would come, and they come broke. But when they get they check, gone… I have let family member stay over the fourteen days, and I have talked to my landlord. Now, I’ll say one thing about the cool, okay, I need some money. So he’s cool with that part. But then they run off. I have to pay that part.

Informant: “If a landlord says, oh, I just noticed that your client has someone living with them that shouldn’t be, or that – oh, my god, my auntie got caught, I was staying with her, what do I do – we can throw money at that problem.”

Interviewer: “And that usually makes it go away.”

Informant: “Yes, but not permanently.”

Typically, the only way to circumvent these limitations is to formalize the arrangement by adding the visitor to the lease. However, this process can be complicated. In subsidized housing, potential tenants must meet certain requirements, and their income would count towards the rent calculation, which is 30% of the total household income (U.S. Department of Housing and Urban Development, 2006). One participant was adamant that they were not staying with their brother in subsidized housing. “It’s a visit. [If I were to move in] his rent will go up. And then they’d be underhoused.” A host noted that having family members and friends stay with them is fine with their landlord except, “Only thing he would do, go up on my rent. And I’m not havin’ that.”

Based on regulations governing the number of people in each unit of subsidized housing, the additional person could trigger the need for a larger apartment to meet housing regulations, which may not be available (U.S. Department of Housing and Urban Development, 2006). One participant described their annoyance with this policy, “Yeah, ‘cause you’d have to go on the lease, and – the rent’s gonna go up. Then if I get ready to move, then you gotta go through the thing, go get it back down. See, that’s a headache.” One host noted, “Mom doesn’t want to add Dad to the lease…because if Dad’s on the lease, then rent goes up, right, because he’s earning money.” Many hosts in subsidized housing feared relying on the homeless adult to contribute reliably to rent. One host said the reason they are having trouble finding housing with the participant is cost. “It’s just really about money… Because he can’t help.”

Those in non-subsidized housing expressed similar concerns about violating lease restrictions by having non-leaseholders staying in the home. Many of these hosts faced economic challenges that hindered their ability to host older adults. Either they themselves were formerly homeless, already hosting other family members, or severely cost-burdened, i.e. spending more than 50% of their income on rent (Joint Center for Housing Studies of Harvard University, 2019). One host, whose only income was social security income, reported spending two-thirds of her household income on rent and had difficulty paying the additional food costs for hosting a family member. “It’s hard for me, because I pay $600 [a month for rent]… that leaves me with not very much to buy food. So I be like really stretchin’ it [when he is staying with me]…”

Multiple participants discussed rent burden as a problem or a reason to not be able to stay at a hosts’ residence. “I stayed there three weeks… He told me that was okay to give him $160 every month. When he found out that I was getting that $416, he jumped it up to $260. Which I couldn’t afford.”

Interviewer: “So you get about $900 and you’ve got to pay $600 to your in-laws.”

Participant: “Uh-huh [yes], plus phone bill, plus food.”

Living with Family Threatens Eligibility for Shelter and Housing

Living with family, as opposed to being unsheltered, could threaten a participant’s eligibility for later use of an emergency shelter. One stakeholder stated that people who stayed with family or friends would likely have a difficult time accessing shelters if they wanted them because they would lose priority (U.S. Department of Housing and Urban Development, 2019). Another stakeholder expressed that this policy was an unfortunate reality given the limited number of shelter beds.

You have to be literally homeless [met the Federal Definition] to be able to get into shelter beds… And when we looked at the data and saw how many people were coming from a situation with family or friends, well, we should focus our energy on the people who are unsheltered first.

Staying with family or friends could threaten homeless individuals’ priority for assistance to obtain permanent housing, which most older homeless participants preferred. Homeless services that receive federal funding use the Coordinated Entry System, which assigns priority for housing resources (U.S. Department of Housing and Urban Development, 2015a). Time spent living with family doesn’t count as time spent homeless, which could lead to lower priority for individuals who stayed with family or friends. To be eligible for PSH, one must meet the definition for chronic homelessness. Chronic homelessness is defined as homelessness lasting for a year or more, or four or more episodes in the prior three years amounting to a year or more, and having a disabling diagnosis (U.S. Department of Housing and Urban Development, 2015b). Since time spent living with friends and family does not count towards the amount of time being homeless, those who stay with family or friends could lose eligibility for PSH. Even if one meets time criteria, some systems will consider a homeless adult ineligible if they are slated to enter PSH directly from a stay with family (U.S. Department of Housing and Urban Development, 2015a). As one stakeholder said: “If it’s HUD-funded supportive housing, people have to be coming from the streets or emergency shelter at the time they enter the program.”

Geographic and Transportation Challenges

Some hosts stated they had to move away from the Bay Area due to rising rental costs. Participants noted that even nearby cities are too expensive. “The further you go out away from the Bay Area, the cheaper the rent is, but – where can I go? I’ve checked outlying cities… it’s still too much money.” As a result, homeless older adults had to travel long distances to stay with family members or friends in often unfamiliar cities. One stakeholder described, “We’ve been moving folks as far as Alabama. Nine times out of ten to… re-unify with family.”

One homeless older adult’s family member offered him a place to stay 40 miles away from his job. Since he could not afford the commute, he turned down the opportunity and remained homeless near his job. Another participant stated his brother lived in a less densely populated area that had limited access to public transportation. The participant feared walking alone so much that when he was there, he carried a screwdriver for protection. A different participant had a similar problem at their sister’s house near the countryside, “They have quite a few outlets [here] but… you’ve got to walk five, six miles to get there and there is no bus to [there], even from here…” Another host mentioned that changing government benefits to a different county could be a barrier to moving. “Definitely would be able to relocate, willing to relocate to a different county, just to be a matter of changing over his medical and all that stuff… but it’s not a problem. It’s just time-consuming.”

Another participant noted transportation as a barrier to moving, “My son tells me I can get a… four-bedroom house in Sacramento for what I’m payin’ for a one-bedroom apartment. Okay, so the only drawback to that would be transportation. So first I have to get a car.” Older homeless adults stated that moving with family or friends could make it more difficult to access health care appointments or case management services due to increased travel times. As one participant stated, “It’s just the commute. The commute is just too much.” Older homeless adults who were on parole or probation faced additional challenges if hosts moved because they were required to serve probation in the jurisdiction where the crime was judged to have occurred. One participant shared a story of finally connecting with family after having to stay in Oakland, on probation, for four years:

I think about a four year period where I had no contact at all with my family and then it’s sort of like a cycle being homeless. [E]specially if you’re on probation, you get picked up, there’s jail and there’s also programs. I went into a program [at] the church that I was raised in was in Oakland, and…my grandmother was there. So it was at that point I started checking in and out with the family but I was still on the streets.”

A host echoed this sentiment:

“I have been looking [for housing], but the thing is, when I was looking… he’d just got his discharge from parole, so he was limited as to where he could go. When you’re on parole, you can’t go beyond 50 miles, and unfortunately, more affordable housing is definitely out[side of]… that area.”

Safety

While stakeholders expressed concern that older homeless adults or their hosts could harm one another, neither older homeless adults nor their hosts reported this concern. Instead, older homeless adults and their hosts expressed concern about exposure to violence in shelters and unsheltered settings. Both older homeless adults and their hosts viewed stays with family and friends as a protective factor against violence. One man said he moved in with his family because he felt too old to face the constant exposure to violence while being homeless. His sister described her motivation for hosting him:

Life on the streets is really hard…. a young guy came up to [my brother’s friend] and told him to get off, that was his bench, and the other guy said, “Who the hell you talkin’ to?” The man pulled out a gun and shot him….then [my brother] called me up, he said, “I can’t do this anymore. Can you come and get me?” I said yes.

Several hosts noted that having their homeless family members stay with them increased their sense of safety. One host stated she no longer feared being assaulted in her apartment complex. “I don’t feel scared [when cousin is around] or—it’s just somebody present. A man. Because when my husband first died, I don’t know, I was nervous about everybody….I know people, know friends, that been gang-raped.”

Crowding

Older homeless adults, hosts, and key informants noted that overcrowding created a barrier to permanent housing. Due to overcrowding, many homeless adults staying with hosts slept in living rooms or common spaces. Stakeholders expressed concern that older homeless adults would stay in suboptimal conditions (i.e. hallway or garage) due to crowding inside the home.

One older adult stayed with his sister in a four-bedroom apartment for which his sister had a Housing Choice voucher (U.S. Department of Housing and Urban Development, 2006). The lease was approved for seven people but 12 people were staying in the four bedroom apartment. The homeless older adult complained about the crowding: “I come home, I can’t get to my room, people all out in the hallway sleepin’ like dogs—it’s all crazy.”

Crowding also prevented residents from having privacy. Many older homeless adults and hosts mentioned the deleterious effects on their routines and intimate relationships. A host noted: “Our sex life was damped down a lot. If [my brother, an older homeless adult] was there, [my husband] was very conscious about sound, noise, the fact that my brother might hear him and that would make him feel extremely uncomfortable.”

Stakeholder Recommendations

Stakeholders made several recommendations to make living with family more safe, dignified, and healthy for older homeless adults. Many stakeholders recognized that stays with family or friends were not a permanent fix for homelessness and feared that focus on facilitating family stays could interfere with the overall goal to expand access to extremely low-income (ELI) housing, i.e. housing affordable to those who make less than 30% of the area median income. One stakeholder summarized this viewpoint:

If you have a choice between funding affordable housing for people of all ages or funding people to strong-arm their friends and family members into giving them a couch to sleep on, do the first one, not the second one. And I feel cranky about the fact that—the consideration is being made, how can we make it even less expensive to house people? How can we make it easier for us not to provide this basic human need?

Another stakeholder expressed concern that policy attention on temporary stays could decrease enthusiasm for other interventions. “There may be some trepidation about saying, shared housing, doubling up with family members, ought to be the right intervention for people [because] some leaders in this work say—’these guys don’t really need supportive housing.’”

Recognizing that the limits on length of visitor stays created impediments for hosts, stakeholders recommended increasing limits on lengths of guest stays in subsidized housing, noting that public housing authorities have the authority to make these changes (U.S. Department of Housing and Urban Development, 2006). They suggested streamlining and strengthening the process for adding individuals to leases in federally subsidized housing. This change could provide protection from evictions for hosts if they temporarily house a family member or friend experiencing homelessness. One stakeholder focused on the mechanics of the process change, calling for a “regimented” process to assess sustainability and need for supportive services to aid in the transitional housing period for the host and the older homeless adult.

I would want there to be a pretty regimented sort of process to [adding people to a Section 8 lease]. I definitely would want there to be a full assessment of, is this gonna be sustainable, how is this gonna work, and that would likely require some supportive services to make that transition period, and periodic check-ins and assessments on how that’s going, and any adjustments that need to be made.

To facilitate these stays, stakeholders recommended increasing legal tenancy protections for both older homeless adults and hosts. One stakeholder suggested that expanding protected classes to include criminal background and tenancy history so that older homeless adults and hosts did not face undue discrimination based on criminal, eviction, and rental histories when pursuing lease agreements.“[Currently] landlords have a huge amount of discretion about whom they screen out from housing based on credit history, tenancy history, history of evictions, criminal background.”

Next, stakeholders recommended increasing financial and material support to facilitate stays. To achieve this aim, one stakeholder suggested providing cash subsidies to hosts to cover the costs of increased rent, food, and utilities. “My personal opinion [on how to make living with family possible] is cash. Cash is cheaper to administer, and it provides flexibility.” Others suggested helping older homeless adults obtain benefits for which they are eligible, allowing them to contribute to household expenses, which would provide financial support to host households while also stabilizing older homeless adults. “I would say that a lot of [homeless older adults] are clearly underbenefitted and that the people who found their way to this housing on their own, without system involvement, probably are not getting all the benefits.”

Discussion

In this study of older homeless adults who had overnight stays with friends or family, friends and family members who hosted them, and stakeholders, participants reported numerous benefits from these stays. In some cases the stays interrupted, and in other cases ended, episodes of homelessness. Both older homeless adults and their hosts viewed these stays as a temporary crisis solution, akin to emergency shelter—rather than as a viable permanent exit. Framing these stays as interim housing—less expensive and potentially better than homeless shelters—could provide a framework to enact appropriate changes in regulations and practices. Doing so would require a change in programs using Coordinated Entry processes to consider the time that homeless individuals stay with family and friends as time spent homeless. This change would facilitate the process of homeless adults staying with their friends or families.

Other necessary changes to facilitate stays include modifying lease rules about visitors and providing financial support for hosts to facilitate stays. Many of the hosts lived in housing supported by a rental subsidy, either Housing Choice Voucher or Public Housing. In these cases, hosts were limited to hosting a guest for 14 consecutive days and 21 days annually (U.S. Department of Housing and Urban Development, 2006). To add an older homeless adult to their lease requires a complex process, including counting the older adult’s household income in the rent calculation, requiring the older adult to meet criteria for housing, and potentially requiring the household to move in order to increase the number of bedrooms (U.S. Department of Housing and Urban Development, 2006). As these requirements may prove onerous and not appropriate for temporary, albeit prolonged, stays, another policy recommendation is for housing authorities to allow extended stays for people experiencing homelessness, without requiring amending the lease. Pilot projects designed to support individuals returning from prison demonstrate precedence for efforts to stay with family living in public housing (Ramírez, 2016). Expansion of similar programs could provide interim housing for older homeless adults.

We found similar issues for hosts living in private market, unsubsidized housing—many of whom feared risking eviction by having a non-leaseholder staying in the home. States and counties could create eviction protections for renters who host family members or friends as a means for them to avoid homelessness (California State Legislature, 2019). Continuum of care organizations, which distribute federal funds for homeless services, or local or state governments could consider giving flexible funds to individuals who are homeless to help defray hosts’ costs. These funds could prove to be less expensive than the cost of homeless shelters. The Canadian coordinated access system, which includes time spent in the homes of family or friends in their definition of chronic homelessness, could be a model for a more inclusive definition of chronic homelessness (Employment and Social Development Canada, 2020). This inclusive definition could facilitate family stays and help people remain eligible for permanent housing who don’t live in unsheltered settings or in emergency shelters.

Homeless adults, hosts, and stakeholders agreed on the need to increase the supply of ELI housing—via both an expansion of subsidies and an increase in housing stock affordable to extremely low-income renters—to provide permanent exits to homelessness. While only some older homeless adults require PSH, all require ELI housing. However, there are extreme shortages of ELI housing, with only 36 units for every 100 ELI households in the United States and 23 for every 100 in California (National Low Income Housing Coalition, 2020). Only one in four adults (and one in three people aged 65 or older) who qualify for federal rental assistance receive it through the Housing Choice Voucher program (National Low Income Housing Coalition, 2020). To assist older adults living on fixed incomes afford housing, some municipalities are expanding local shallow subsidies on the order of a few hundred dollars monthly, but demand outstrips supply (City of Santa Monica, 2019). Increasing the funding to and availability of shallow subsidies, particularly for older homeless adults and their hosts, could alleviate this crisis.

Our research raises questions about the role of case managers in encouraging and supporting stays with family and friends. The majority of HOPE HOME participants reported social support during the last period of stable housing: 64.8% had someone to stay with and 69.0% had someone to lend them money (Lee et al., 2016). It is crucial to create a system that supports case managers in finding supportive family and friends with the help of the individual experiencing homelessness. Stakeholders reported that case managers would ensure the safety of homeless adults who stayed with friends or family, while hosts and homeless guests felt case managers would add an intrusive presence into family dynamics. Given the promise of using stays with family and friends as an emergency response to homelessness, there is a need for real-world evaluation of these policies. (Bush & Shinn, 2017; Shinn et al., 1991). People experiencing homelessness and their families should contribute to the development of such policies.

Our study has several limitations. Oakland, California, where this study is located, has a higher population of Black residents than the country as a whole. While approximately 40% of all Americans experiencing homelessness are Black,(Henry et al., 2021) almost 80% of those in the HOPE HOME study are,(Lee et al., 2016) reflecting the higher proportion of Black residents of Oakland, CA. We purposively sampled those who stayed with family or friends, leading to a slightly higher proportion of Black participants than the sample as a whole. Due to the high proportion of Black older adults experiencing homelessness in our sample, our results may not generalize to white or Latinx older adults experiencing homelessness. Furthermore, we conducted a purposive sample of homeless adults in Oakland, a convenience sample of hosts they had stayed with, and a snowball sample of stakeholders. We did not collect data on participants who did not report temporary stays with family or friends, or on those family or friends who did not serve as hosts. Therefore, we are unable to determine whether the community and policy level factors we identified would be equally relevant to those groups. These samples may not represent their respective populations. Additional research should evaluate the generalizability of these results in other settings and evaluate the effectiveness of policy proposals in this study.

Conclusion

Recognizing the potential and limitations of older homeless adults staying with family and friends could lead to an alignment of policies that match the practice. Most older homeless adults who stayed with family and friends saw it as a temporary, crisis response that was preferable to emergency shelters but not to permanent housing. Recognizing this strategy—and optimizing policies to allow for it to be used to its full potential—could lessen both the need for emergency shelters and unsheltered homelessness. Policymakers can facilitate the safe and effective practice of living with family or friends by: (1) classifying these stays as interim housing for the purpose of Coordinated Entry assessments; (2) creating opportunities for extended stays by allowing exceptions to rules on subsidized housing visits and by drafting tenant protections for renters who house homeless adults; (3) providing flexible funds to defray costs associated with stays; and (4) streamlining the ability to add older adults to lease in subsidized housing for long-term stays. None of these policy changes obviate the need for more ELI housing and housing subsidies to provide permanent exits to homelessness. Future research should include experimentation and evaluation of living with family as a temporary means of addressing homelessness.

Biography

Christopher Cai, BA

Christopher Cai is a fourth-year medical student at the University of California San Francisco (UCSF). His work on Medicare for All financing has been published in PLoS Medicine, featured on ABC news and shared by members of Congress. During medical school, he interned with U.S. Representative Pramila Jayapal (D-WA) and was a board member of Students for a National Health Program (SNaHP). He hopes to pursue a career at the intersection of politics and clinical medicine.

Kelly R. Knight, PhD

Kelly Ray Knight, PhD is a medical anthropologist and Associate Professor & Vice-Chair in the Department of Anthropology, History and Social Medicine at University of California San Francisco (UCSF). Her work centers on the experiences of poverty and addiction in clinical and policy contexts, racism and health disparities, and health conditions produced or exacerbated by structural violence. Dr. Knight’s NIH-funded research explores the health, social and policy implications of homelessness in California and the clinical and social consequences of the UC opioid overdose crisis. She has spear-headed efforts in medical education reform at the UCSF School of Medicine, and nationally, related to addiction medicine and structural competency.

Pamela Olsen, MA

Pamela Olsen is a Research Project Manager at University of California, San Francisco’s Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center. Before joining UCSF, she worked for 20 years with vulnerable populations as a criminal and legal investigator in California and Nevada, including on post-conviction mitigation for those sentenced to death. She has a master’s degree in Gerontology and has worked with Dr. Kushel on her longitudinal research of older people experiencing homelessness in Oakland, California (HOPE HOME). She also manages an NIH-funded research project on Advance Care Planning for older, vulnerable populations who have experienced homelessness. Her work centers on issues of homelessness, poverty and other structural inequities that contribute to vulnerabilities.

John Weeks

John Weeks has been with UCSF for 11 years. His most recent research project involved the study of homelessness among people age 50 and older in Oakland, CA. Prior to that, John had worked as a Project Coordinator for the Bruthas Project, which was a CAPS intervention study focusing on HIV prevention among MSM populations in San Francisco and Oakland. John joined Dr. Kushel’s HOPE HOME Study in August 2015 as a Clinical Research Coordinator.

Margaret A Handley, PhD, MPH

Margaret Handley is a public heath trained epidemiologist in the Departments of Epidemiology and Biostatistics and at the Center for Vulnerable Populations, at the University of California San Francisco. Her research focuses on implementation science and bridging the fields of primary care, public health, and health communication.

Dr. Handley co-directs the UCSF Program in Implementation Sciences. She has methodological expertise in practice-based research, community-engaged research, quasi-experimental designs, implementation science, and mixed methods.

Margot B. Kushel, MD

Margot Kushel, MD is a Professor of Medicine at University of California San Francisco, and Division Chief and Director of the UCSF Center for Vulnerable Populations, and Director of the UCSF Benioff Homelessness and Housing Initiative. She is a practicing general internist at Zuckerberg San Francisco General Hospital. Margot’s research focuses on the causes and consequences of homelessness and housing instability, with the goal of preventing and ending homelessness and ameliorating the effects of homelessness on health. She speaks at a local, state and national level about issues of homelessness, and provides testimony to legislative bodies. She received her AB from Harvard College, her MD from Yale and completed residency, chief residency and fellowship in internal medicine at UCSF.