Executive summary

Purpose of the review

The purpose of this review was (i) to find and summarise all the available research evidence on the quality and costs of dispersed community-based housing when compared with clustered housing, (ii) to assess the strength of the research and identify gaps in the evidence and (iii) to interpret the research to outline the benefits and drawbacks of each model.

Studies reviewed

This review found 19 papers based on 10 studies presenting data comparing dispersed housing with some kind of clustered housing (village communities, residential campuses or clusters of houses). This is a sizeable body of research reporting the experience of nearly 2500 people from four different countries. The studies covered all eight domains of quality of life, providing information about 80 different aspects of these domains. Five studies included data on different aspects of service design and operation and three presented comparative costs. Almost all of the studies used quantitative methods with robust approaches to measurement. All studies focused on people with intellectual disabilities.

Results

Dispersed housing has been found to be superior to clustered settings in at least some aspects of every domain. Generally, clustered housing provides poorer outcomes than dispersed housing for people with intellectual disabilities. In terms of the quality of life domains of social inclusion, material well-being, self-determination, personal development and rights there are no studies reporting benefits of clustered settings. In the physical well-being domain, clustered settings have been found to be superior in hours of recreational activity, contact with dentists, psychiatrists and psychologists, some health screening, some aspects of safety, contact with family and friends, visitors to the home and satisfaction with relationships.

However, in many of these cases the better results refer only to village communities and not to campus housing or clustered housing. These serve a minority of the less disabled population and they depend on a supply of people willing to live communally with disabled residents. They are therefore an important part of the spectrum of service provision but they are only ever likely to occupy a niche in the market for care. They are unlikely to be a feasible option across the board for disabled people.

In terms of costs, the commonest finding is that clustered housing is less expensive than dispersed housing. However, this cost difference appears to be due to differences in staffing levels - ie fewer staff are provided to support people in clustered housing than in dispersed housing. In two of the three studies which examined costs controlling for this variable there was no statistically significant difference - in one case between specialised campus and specialised dispersed housing and in the other between samples matched for client characteristics.

Conclusion

There is much less evidence comparing clustered settings with dispersed housing than comparing other congregate care settings (such as institutions) with dispersed housing. The results should therefore be treated with caution. They do, however, present a broadly consistent picture.

Dispersed housing appears to be superior to clustered housing on the majority of quality indicators studied. The only exception to this is that village communities for people with less severe disabilities have some benefits; this is not however a model which can be feasibly provided for everyone. Clustered housing is usually less expensive than dispersed housing but this is because it provides fewer staff. There is no evidence that cluster housing can deliver the same quality of life as dispersed housing at a lower cost.