Via Research Recognition Day Program VCOM-Carolinas 2025

Clinical Educational Research

Transformative Tiny Home Housing: A Novel Approach to Permanent Supportive Housing for the Chronically Homeless at Eden Village of Wilmington

Holt Evans, Chase Berman, Dr. Alexis Stoner, Dr. Kiran McCloskey .

Background

Results

Discussion

. Unhoused individuals suffer a significantly increased risk of premature morbidity and mortality when compared to the rest of the population and members of marginalized populations are overrepresented among individuals experiencing homelessness in the US (Fazel et al., 2014; National Alliance to End Homelessness, 2023). In 2023, North Carolina was estimated to be home to roughly 7,200 homeless individuals, roughly 8% of whom were residing in and around the small coastal city of Wilmington, NC (United States Department of Housing and Urban Development, 2023; Dill, 2023). In response to the growing homelessness in the area, a non-profit 501(c)(3) organization named Eden Village of Wilmington opened a 31 unit tiny home community to provide permanent supportive housing and comprehensive case management for chronically homeless individuals in the area. Upon move-in, residents receive comprehensive case management services from the Eden Village social work team, monthly primary care visits through Novant Health, and personalized volunteer support services. Eden Village of Wilmington also employs a robust resident data collection program to guide delivery of case management services and iteratively tailor community operations to better meet the needs of the overall cohort. Upon acceptance to Eden Village, residents give their informed consent to participate in five brief surveys at baseline and every 4 to 6 months assessing childhood trauma (intake only), psychological symptoms (Modified Colorado Symptom Index), functional impairment (Brief Instrumental Functioning Scale), and health-related quality of life (Rand SF-36 Item Health Survey). Assessment results enable Eden Village case managers to implement plans for alleviating residents’ pressing concerns while developing strategies for meeting their long-term goals. The purpose of this study is to describe the novel case management model and preliminary results of the Eden Village of Wilmington Resident Data Collection Program, and in doing so, we hope that our findings will provide insight into the utility of tiny home communities for combating chronic homelessness across the country. ● A retrospective cohort study was conducted to analyze changes in Eden Village resident responses to routine case management assessments when surveyed at move-in and after 4 to 6 months of life within the tiny home community. ● Eligible participants were residents who completed both baseline assessments between summer 2021 and spring of 2023 and follow-up assessments during January and February of 2024. Exclusion criteria included residents without follow-up assessments, those who moved in after data abstraction, and those who declined participation. ● Instruments used included the Adverse Childhood Experience Questionnaire for Adults (ACE-Q), Modified Colorado Symptom Index (CSI), Brief Instrumental Functioning Scale (BIFS), and Rand SF-36 Item Health Survey Instrument (SF-36). ● Data abstraction and de-identification were conducted via the Eden Village Confidential Data Collection and Management System in Salesforce. The de identified dataset was securely delivered to the research team and analyzed on VCOM’s secure network. ● Descriptive statistics were performed by Dr. Kiran McCloskey, and two sample T-tests were used to compare mean resident scores at baseline and follow-up. ● The Edward Via College of Osteopathic Medicine Institutional Review Board determined this project does not meet the definition of human subject research (IRB # 2024-168). Methods

● The study cohort from Eden Village of Wilmington had a high representation of marginalized racial groups, with 50% identifying as Black/African American (n=13) and 7.7% as American Indian/Alaska Native (n=2). Wilmington, NC, has a history of structural racism influencing housing disparities, with local data showing a strong correlation between race and housing burden. By serving individuals from marginalized backgrounds, Eden Village helps address housing insecurity driven by structural racism, historic inequities, and systemic barriers to generational wealth. ● Sixteen residents experienced four or more adverse childhood events (ACEs), reflecting research linking childhood trauma to homelessness. Homeless individuals face higher rates of childhood trauma and associated health risks. Eden Village integrates trauma-informed care into case management to mitigate long-term effects of ACEs, build resilience, improve health outcomes, and support housing stability. ● Initial (though statistically insignificant) improvements were observed in resident health outcomes after moving into Eden Village. Notably, Modified Colorado Symptom Index scores improved, suggesting a reduced mental health burden. Positive trends, though not significant, were seen in SF-36 and Brief Instrumental Functioning scores. While small sample size limits statistical significance, these trends indicate potential benefits of the Eden Village model in improving health outcomes for chronically homeless individuals, underscoring the importance of continued assessment. ● Study limitations include selection bias, as residents who did not provide consent, left the community, or had not completed follow-ups were excluded. Self-reported survey data introduce response bias, and interviewer bias remains possible despite the use of a strict script. Residents also engage in external services and maintain personal support networks, which may confound outcomes. The small sample size (n=26) limits statistical power. ● This study underscores the potential of integrating tiny home living with comprehensive case management to address health disparities in a permanent supportive housing model. While PSH interventions are well-documented in improving housing stability, their long-term effects on mental health and quality of life remain uncertain. Given the limited research on tiny home- based supportive housing, continued evaluation of Eden Village’s model is essential to understanding its broader impact on chronically homeless individuals.

On average, Eden Village residents experienced more adverse childhood events than members of the general population in the United States (Madigan et al., 2023). Sixteen of the twenty-five residents surveyed (61%) reported experiencing four or more ACE scores (Figure 1). In comparison, only around 13-17% of the population at large report experiencing four or more adverse childhood events (Swedo et al., 2023).

Compared to baseline, resident scores on the RAND SF 36 Health Survey, Brief Instrumental Functioning Scale, and Colorado Symptom index improved after participating in the Eden Village case management model. Mean Colorado Symptom Index score for participants at intake was 22.7 (SD= 17.9) and decreased to 13.4 (SD=11.6) at follow up. Residents exhibited a 9.3 point decline in score on average, indicating that they felt less emotionally distressed at their follow up appointment after having lived at Eden Village and received comprehensive case management services for 4 to 6 months (Figure 2). This result was found to be statistically significant via paired t-test (p<0.001).

Conclusion

● In conclusion, Eden Village of Wilmington has implemented a novel approach to permanent supportive housing for the chronically homeless by integrating a tiny home community with the provision of comprehensive case management services. ● This model prioritizes the well being of residents from marginalized racial groups within the Wilmington community as well as vulnerable individuals who have experienced significant childhood trauma. While not statistically significant and likely subject to a degree of confounding, resident assessment scores demonstrated general improvement in prevalence of adverse mental health symptoms, instrumental functioning, and self reported health status after four to six months of life at Eden Village. ● Future studies should focus on continued analysis of follow up assessments for members of the Eden Village cohort over time and as well as the impact of other tiny home based approaches to permanent supportive housing on the health outcomes of formerly homeless residents.

Resident scores on the RAND SF 36 Health Survey also improved between baseline and 4 to 6 month follow up. Scores across all 8 domains measured by this instrument improved by an average of 16.7 points, indicating an improvement in self-reported health status from baseline after living at the tiny-home site and participation in the Eden Village Case management model (Figure 3). The score difference was only deemed to be statistically sig nificant for the “Role Limitations due to Emotional Problems” survey domain (p<0.001) possibly indicating residents’ improved perception of their own capabiliti es to contribute to the community after being assigned responsibilities within Eden Village (gardening, supervision of overnight shelters, assisting with site security) and receipt of emotional health services through organizations like Coastal Horizons. Limitations in sample size (n=26) likely also played a role in the limited significance of these results as well.

References

1. Dill, E. (2023). Despite investments, “snapshot” count shows climbing homeless population in Wilmington. Wilmington Star-News . Retrieved October 8, 2024, from https://www.starnewsonline.com/story/news/local/2023/05/22/homeless-population-in-wilmington-nc growing/70211051007/ 2. Fazel, S., Geddes, J. R., & Kushel, M. (2014). The health of homeless people in high-income countries: Descriptive epidemiology, health consequences, and clinical and policy recommendations. The Lancet, 384(9953) , 1529 – 1540. https://doi.org/10.1016/S0140-6736(14)61132-6 3. Madigan, S., Deneault, A., Racine, N., Park, J., Thiemann, R., Zhu, J., Dimitropoulos, G., Williamson, T., Fearon, P., Cénat, J. M., McDonald, S., Devereux, C., & Neville, R. D. (2023). Adverse childhood experiences: A meta‐analysis of prevalence and moderators among half a million adults in 206 studies. World Psychiatry , 22 (3), 463 – 471. https://doi.org/10.1002/wps.21122 4. National Alliance to End Homelessness. (2023). Homelessness and Racial Disparities . National Alliance to End Homelessness. Retrieved November 17, 2024, from https://endhomelessness.org/homelessness-in-america/what-causes-homelessness/inequality/ 5. Swedo, E. A. (2023). Prevalence of Adverse Childhood Experiences Among U.S. Adults — Behavioral Risk Factor Surveillance System, 2011 – 2020. MMWR. Morbidity and Mortality Weekly Report , 72 . https://doi.org/10.15585/mmwr.mm7226a2 6. United States Department of Housing and Urban Development. The 2023 Annual Homelessness Assessment Report (AHAR to Congress) Part 1: Point-In-Time Estimates of Homelessness, December 2023. https://www.huduser.gov/portal/sites/default/files/pdf/2023-AHAR-Part-1.pdf

Residents’ Brief Instrumental Functioning Index scores remained relatively unchanged after involvement in the Eden Village pr ogram. Participants only exhibited a 0.4 point increase in score between intake and follow up (Figure 4). This observed difference was not found to be statistically significant via paired t-test (p=0.14), indicating a lack of significant improvement in resident’s abilities to perform activities of daily living over the course of the study period. This lack of demonstrated change in resident’s functional capacity could stem from limitations in sample size (n=26), the fact that some residents’ chr onic health problems worsened after their move-in-date, or that 4 to 6 months of living in the Eden Village community was not a long enough time period to effect meaningful change in this parameter.

2025 Research Recognition Day

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