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Article by Jordan Rosenfeld

In 2018, Providence St. Joseph Health served states that accounted for an estimated 36% of the homeless population of the United States. The health system’s president of operations and strategy, Mike Butler, wanted to invest as much money and energy in combating this problem as possible.

By putting their chronically ill homeless patients into structured housing, they not only reduced hospital visits and healthcare costs but improved the quality of life of the patients. In Napa, California, when chronically ill homeless patients’ were supported through a program called CARE, which helped house the homeless, their use of the emergency department dropped by 74% as compared with the prior year.

Many organizations are taking a closer look at how to solve problems around social determinants of health (SDOH), including housing, education, employment and access to food.

Housing is especially critical to the health of chronically ill patients. Studies have shown that people of lower socioeconomic status (SES) with chronic disease are more likely to report worse quality of health and seriousness of symptoms than those of higher SES. This population is also more likely to struggle with substandard housing, housing instability and homelessness. They are more likely to be high utilizers of the emergency department and to experience frequent readmission. Physicians, healthcare organizations and payers are beginning to take this link seriously, particularly in a landscape shifting toward value-based care, where physicians are measured and reimbursed on patient quality outcomes.

Payers see the value of investing in housing

In an effort to reduce costs and improve outcomes, payers are increasingly investing in social interventions such as housing projects for their underserved populations. CVS Health Aetna announced in 2019 that it has invested $67 million in affordable housing, creating more than 2,200 affordable homes with supportive services in six states. Nearly 300 of those units will be Permanent Supportive Housing (PSH) units especially designed for people in challenging life and health situations, such as homelessness, chronic illness and behavioral health issues.

The nation’s largest insurer, UnitedHealth Group, has spent more than $400 million on affordable housing. CEO Steve Nelson said in a statement, “Access to safe and affordable housing is one of the greatest obstacles to better health, making it a social determinant that affects people’s well-being and quality of life.”

Anthem Blue Cross Blue Shield has also recently partnered with the city of Indianapolis, Indiana to create a short term, transitional housing program known as the Blue Triangle Housing Program. The program is a collaboration that includes Anthem, the City of Indianapolis, a non-profit housing organization, and a community mental health center (CMHC). Anthem funds and supports patients’ healthcare and social services navigation, and helps clients with their housing needs.

A value-based landscape

In a new era of value-based care, it is in the physician or the hospital’s best interest to keep patients housed and healthy, as providers are increasingly rated and reimbursed based on patient outcomes.

Providence St Joseph Health tackles the housing issue from several angles. Barry Ross, RN, MPH, Regional Director for Community Health Investment at Providence St. Joseph Health in California, said that when a homeless patient comes into their hospitals, they are assigned a care navigator who builds a relationship with the patient and sets them on the path to housing, and thus better health outcomes. This is not always an instantaneous process, often involving several steps such as helping them to get an ID first, but the goal is to keep their utilization of the hospital down and to improve their health outcomes.

In addition to working on homelessness, they also try to address issues of sub-standard housing by working at the city or county level to address housing code violations where landlords may not have made necessary upgrades to bring a home up to health safety. “[Physical environment] contributes directly to health problems, chronic disease and can have harmful effects on child development,” Ross said. “Poor indoor air quality can affect people with asthma. Lead paint can cause lead poisoning. Water leaks, pest infestations can impact allergies and asthma. Extreme lows and high temperatures can affect vulnerable populations such as the elderly. And residential crowding has been linked to tuberculosis and respiratory infections,” Ross said.

Sometimes, particularly for low-income and immigrant families, Ross said, people may be reluctant to inform their landlord about housing problems for fear of eviction. Physicians can then be advocates for their ill patients if they learn about substandard conditions.

“Rather than just giving the patient the inhaler, the medication, you might also then talk about whether they are in contact with somebody from a housing authority,” said Thomas G. Bognanno, President and CEO of Community Health Charities in Virginia.

On an even larger scale, Providence St. Joseph Health system recently gave a bridge loan to Jamboree Housing in Anaheim, CA, a project to convert a motel into 70 affordable housing units. Other similar projects are in the early planning stages.

Housing as healthcare

A chronically ill patient without a stable home may not have anywhere to keep medications, or a way to keep track of medical appointments said Greg Golin, CEO of CareLync Home, a case management service provider in Pennsylvania. Healthcare providers doing follow-up care may not be able to track them down to assess their recovery. “If somebody doesn’t go to their primary care physician within seven days after release from a hospital, there’s a very high rate of return,” Golin said.

Healthcare providers can glean important housing information by adding a few simple screening questions to their regular intake forms, said Ross. A physician, medical assistant or social worker can even just ask these questions in real time, in the waiting room or the exam room.

Questions might include whether the patient is concerned about losing or affording housing, if they have enough food to eat, and whether they have mold or pests in their homes, Ross suggested. “Doing a proactive screen helps you avoid the point where it becomes problematic from a clinical perspective.”

Without addressing the challenge of housing stability, chronically ill patients may not see improvement, Bognanno said. “Anything less is simply putting Band-Aids on a disparity problem that will only grow worse over time.”

Housing the chronically ill requires efforts from every prong of healthcare, Ross explained. “When you’re dealing with SDOH like housing, you have to engage with many partners to have an effective outcome. It takes a great deal of collaboration.”


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