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By Sarah C. Threnhauser, MPA

The housing issue comes up in almost every meeting of health and human service executives. These conversations include the difficulty of discharging consumers from the hospital because they don’t have suitable/stable housing; the challenges of community reentry from corrections facilities because of lack of housing options; housing insecurity and its effect on family preservation in the child welfare field; the “housing first” initiative for people with addictions. The focus on “home and community” services—all dependent on stable housing.

So, I wasn’t surprised to read the study recently published in the Journal of the American Medical Association that found half of community health center consumers have experienced housing instability (see Prevalence of Housing Problems Among Community Health Center Patients). But the housing issue is another social determinant that health plans and provider organizations will need to address if they are going to maximize their performance in value-based contracts.

The literature linking housing instability and health care costs is extensive. A 2016 study conducted by the Center for Outcomes Research and Education (CORE) found housing reduced overall health care expenditures by 12% ($48 dollar per month) for Medicaid recipients (see Study Finds Affordable Housing Reduces Health Care Costs). In addition, an evaluation report of Massachusetts’ Home and Healthy for Good Program, and reported on by the Corporation for Supportive Housing (see Housing Is The Best Medicine: Supportive Housing And The Social Determinants Of Health), found in a survey of chronically homeless individuals that six months prior to housing, participants accumulated 1,812 emergency department visits, 3,163 overnight hospital stays, 847 ambulance rides, and 2,494 detox stays. The estimated total cost per person for measured services. The total spent included Medicaid ($26,124), shelter ($5,723) and incarceration ($1,343)-or $33,190 per year. After housing, that cost fell $8,603 per consumer.

In response to the data, we are seeing a lot of one-off initiatives around the country. For example, in just the last few months, we’ve seen a variety of initiatives across the country, including:

  1. New York Creates 459 New Housing Opportunities For People With Developmental Disabilities
  2. Illinois Housing Development Authority Launches Its First Single-Site Supportive Housing Development For Adults With I/DD
  3. Portland & Multnomah County To Add 2,000 New Supportive Housing Units By 2027
  4. San Diego City Council Approves $6.5 Million For ‘Bridge Shelter Program’ To Temporarily House Homeless
  5. Los Angeles County Launches First Pay-For-Success Project: ‘Just In Reach’ Supportive Housing Program

On the ground, the organizations serving complex consumers are focused on making the link between support services and housing.  I recently spoke with Marco Giordano, Chief Executive Officer of Resources for Human Development (RHD), a national human services organization based in Philadelphia. RHD serves more than 50,000 adults and children in 14 states, including multiple supportive housing programs. Mr. Giordano explained:

RHD believes that housing a basic human right. But our long history of supporting people in need has also shown without question that services are more effective and efficient if people have safe, affordable and stable housing. Housing insecurity creates such stress and instability that it is a massive barrier to recovery. A lack of housing leads to more hospitalizations and other medical costs, a much higher rate of involvement with the criminal justice system, and enormous mental health challenges. If you take away that barrier by providing stable housing, a person’s other challenges become a lot more manageable. With that foundation, people have a far greater chance of success. However it can’t just be housing – case management and supportive services that help build life skills, social skills, and job skills are absolutely crucial. But none of it works if you don’t start with stable housing.

How do these programs fit into the big picture of housing in the U.S.? According to a 2017 report from The Urban Institute, Trends In Housing Problems And Federal Housing Assistance, housing needs have grown substantially and federal housing assistance has not kept up. The report found that the number of households that report either housing problems and/or government housing assistance increased from 18 million in 2005, to 22.3 million in 2015. Specifically for households receiving United States Department of Housing and Urban Development (HUD) project-based assistance, the report found:

  1. The number of households in public housing dropped from 1.14 million in 1993 to 1.02 million in 2016.
  2. Households assisted in privately owned subsidized projects declined from 1.72 million in 1993, to 1.37 million in 2016.
  3. Households receiving HUD deep subsidy assistance increased from 4.06 million in 2003 to 4.69 million in 2016.
  4. Beneficiaries served by HUD programs shifted away from families with children, and toward the elderly and disabled.

The report also sums up the current administration approach to the future of HUD programs, and has proposed major cuts to most HUD programs for fiscal year (FY) 2018, including reducing the budget for Housing Choice Vouchers from their $20.3 billion to $19.3 billion, the public housing budget from $6.3 billion to $4.5 billion, and eliminating funding for HUD’s block grant programs ($3.0 billion for Community Development Block Grants and about $1 billion for HOME). If this budget change happens, health insuring organizations will likely need to increase their role in coordinating housing for their members. The question will be what is the framework for that coordination that will be cost effective – Social Risk & The ‘Value’ Of Health Care, Paying For Social Services ‘Value’ Requires Measuring Cost Impact, and A State-Led Framework For Value-Based Purchasing To Incent Integration.

For more from the OPEN MINDS Industry Library on housing, check out these resources:

  1. Supported Housing In Action
  2. What Is “Housing First”?
  3. Is Supportive Housing Your Next Service Line?
  4. The Housing To Heath Care Evolution
  5. For Supportive Housing, Creativity Required
  6. A Question Of Permanent Supportive Housing

For more on developing the innovative service lines that will be needed in the future, as the field further embraces the need for SDH-focused solutions, join OPEN MINDS Senior Associate Annie Medina on August 14 for her session at the Executive Summit for The 2018 OPEN MINDS Management Best Practices Institute, Designing & Implementing Innovative Treatment Programs: An OPEN MINDS Executive Summit & Showcase.

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