Nursing leadership in housing first implementation: A comparative analysis of care coordination approaches across four U.S. states

BACKGROUND: Homelessness affects over 650,000 Americans annually, with 25% to 30% experiencing co-occurring mental health and substance use disorders. Despite evidence supporting Housing First approaches, implementation remains inconsistent across states, leading to fragmented care delivery and persistent housing instability for vulnerable populations. PURPOSE: To analyze Housing First implementation across four U.S. states and identify nursing practice and policy implications using the Minnesota Public Health Intervention Wheel framework. 

METHODS: Comparative case study analysis of Housing First policies across California, Utah, Oregon, and Minnesota (2014-2025) using integrated Multiple Streams Framework and Health Policy Triangle approaches. Analysis examined policy adoption dynamics, implementation structures, and nursing contributions through case management, outreach, consultation, and systems-level advocacy. 

RESULTS: Four generalizable implementation pathways emerged: High-Mandate/Variable Practice (California), Transitional/Evolving (Utah), Emergent-Practice/Collaborative (Oregon), and Mature/Sustainable (Minnesota). Governance capacity and cross-sector coordination proved more critical than legislative mandate strength. States with integrated Medicaid financing and stable interagency coordination demonstrated superior outcomes, with nursing coordination improving medication adherence (45%-50% to 70%-85%), reducing psychiatric readmissions (25%-40%), and decreasing emergency department utilization. 

CONCLUSION: Nursing leadership significantly enhances Housing First implementation effectiveness. Medicaid-funded care coordination, operationalized through public health nursing interventions, demonstrates pathways toward comprehensive care improving housing stability and health outcomes for vulnerable populations.