According to the National Alliance to End Homelessness, on a single night in January 2017 there were over 86,000 chronically homeless individuals in the United States (24% of the total national homeless population).[i] A person is considered chronically homeless when they “have experienced homelessness for at least a year—or repeatedly—while struggling with a disabling condition such as mental illness, substance use disorder, or physical disability.”[ii] Unsurprisingly, there is a direct connection between homelessness and poor health.[iii] But evidence also shows that when housing support is integrated with healthcare, it improves patient adherence to medication regimens and treatment plans and results in fewer visits to the emergency room and fewer hospital admissions.[iv]
When you give someone permanent housing, you establish trust with that person,[v] which allows you to better engage them with healthcare and other services. Housing can be a gateway to helping people address the factors contributing to their homelessness and can enable them to achieve healthier, more stable lives. When housing and healthcare work together, it not only improves people’s health and reduces the costs of care, it helps them break the cycle of chronic homelessness.[vi]
Making housing a component of “whole person” healthcare takes close coordination between healthcare systems, housing programs, other social service organizations, and public agencies—entities that often have never worked together before. At times this can make for something like culture shock. In Phoenix, Arizona, Mercy Maricopa Integrated Care, a nonprofit healthcare plan, partners with the City of Phoenix Housing Department and the local United Way to provide supportive housing services as well as physical and mental healthcare and substance abuse treatment to homeless individuals with mental illness.[vii] But before they could get their initiative off the ground, Mercy Maricopa and the Housing Department first had to learn about the policy environments affecting each other’s programs, as well as their unique financing structures. They had to align their goals and their approaches, and make sure they understood their own and their partners’ roles. Because they took the time to lay that foundation, they were able to build an extremely effective program that leverages the strengths and resources of all partners: Preliminary data from this program show that between November 2014 and October 2015, psychiatric hospital admissions for the served population dropped by 46% and utilization of crisis services dropped by a third.[viii]
It is also critical that partners implement systems to coordinate their communication and facilitate the delivery of integrated services. SD United, a care coordination network for veteran-serving organizations in San Diego, adopted the Unite Us technology to connect the members of its network. This allows a range of social services, including housing programs, healthcare providers and substance abuse treatment, to easily cross-refer their clients to each other. Alpha Project, a San Diego nonprofit, launched its Rapid Rehousing Project in December 2016 and joined SD United shortly thereafter. By June 2017, only six months after the program began, Alpha Project had linked 50 veterans with housing, 31 one of whom were referred through the SD United network. What is more, because the referral now comes complete with all of the necessary documentation, Alpha Project has been able to significantly reduce the time between the referral and a placement in housing, in some cases to as little as two days.[ix]
Finally, partners must creatively leverage funding streams to support their collaboration. For example, in Philadelphia, the City Office of Homeless Services has reinvested Medicaid savings into an initiative that places chronically homeless and mentally ill individuals in stable, secure housing and provides them the services they need to remain healthy and off the street. After eight years, 89% of the chronically homeless individuals who entered the program remain housed and the cost of providing them with behavioral health services has dropped nearly 80%.[x] (In fact there are multiple ways to leverage Medicaid funds to integrate housing supports with healthcare, including Medicaid Research and Demonstration programs, Community Based Services waivers, and reimbursement for Targeted Care Management services. [xi]) Private funders are also increasingly interested in investing in innovative approaches to decreasing chronic homelessness. Funders Together to End Homelessness, for example, currently has over 200 members, including leading philanthropies like the Bill and Melinda Gates Foundation, the Robert Wood Johnson Foundation, and the Robin Hood Foundation.[xii]
Building partnerships to integrate healthcare and housing can be challenging. But as the collaborations described here show, it can be done, and there are resources available to help. If healthcare systems, public agencies and nonprofit organizations in other cities were to follow the examples set in Philadelphia, San Diego and Phoenix, it could change the course of tens of thousands of lives.
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About the Author: Stefanie Lindeman blogs on health equity and the social determinants of health at Stairway to Healthcare (stairwaytohealthcare.com).
[i] National Alliance to End Homelessness, available at https://endhomelessness.org/homelessness-in-america/who-experiences-homelessness/chronically-homeless/
[iii] Paradise & Ross
[v] Lloyd Pendleton, The Housing First Approach to Homelessness, TEDMED 2016, video and transcript available at https://www.ted.com/talks/lloyd_pendleton_the_housing_first_approach_to_homelessness/transcript#t-810988
[vi] Office of Policy Development and Research, U.S. Department of Housing and Urban Development, Linking Housing and Health Care Works for Chronically Homeless Persons, Evidence Matters (online newsletter) Summer 2012, available at https://www.huduser.gov/portal/periodicals/em/summer12/highlight3.html
[viii] Paradise & Ross
[ix] Unite Us Housing Case Study, Alpha Project Successfully Houses 50 Homeless Veterans; also SD United website, https://sandiegounited.org/about-sd-united/; Alpha Project website, https://www.alphaproject.org/about-us/mission-and-history
[x] Julia Paradise, Kaiser Family Foundation, and Donna Cohen Ross, Health Management Associates, Linking Medicaid and Supportive Housing: Opportunities and On-the-Ground Examples, Issue Brief Jan. 2017, available at http://files.kff.org/attachment/Issue-Brief-Linking-Medicaid-and-Supportive-Housing-Opportunities-and-On-the-Ground-Examples
[xi] Paradise & Ross; also Stuart M. Butler, Dayna Bowen Matthew & Marcela Cabello, Rebalancing medical and social spending to promote health: Increasing state flexibility to improve health through housing, posted Feb. 15, 2017, available at https://www.brookings.edu/blog/up-front/2017/02/15/re-balancing-medical-and-social-spending-to-promote-health-increasing-state-flexibility-to-improve-health-through-housing/
[xii] Funders Together to End Homelessness website, http://www.funderstogether.org/members_alphabetically