The overlap between housing and health care continues to blur. The reason is clear—people with housing insecurity are likely to use more health care resources, particularly hospitalization. A recent report looking at hospitalizations among the homeless population in three states found hospitalizations increased by an average of 38.4% from 2007 to 2013. The increase over this period varied by state. In California, the increase was from 133 to 164 per 1,000 homeless people (23.3%); in Florida, the increase was from 161 to 240 per 1,000 homeless people (49.4%); and in Massachusetts, the increase was from 294 to 420 hospitalizations per 1,000 homeless people (42.9%). Approximately 52% of these 185,292 hospitalizations were for mental illness or addiction disorder (see Hospitalization Among Homeless Adults Rose 38.4% Between 2007 & 2013; Over Half Were For Behavioral Disorders).
As I read this, I started to wonder about the math. We know that on any given night, there are over 553,000 homeless individuals in the United States (see How Many Shelter Beds Are Enough?). And, according to the study referenced previously, there are 240 hospitalizations each year per 1,000 homeless people, with an average cost per stay of $10,391. Using that rough math, we’re talking about $1.4 billion per year in hospitalization expense for this population.
The immediate question for any organization that is looking to control health care costs in general and hospital admissions is—how many of the admissions for homeless people are preventable? There is no definitive answer to that question, but we do know that when a consumer who is a high utilizer of health care services gains supportive housing, average hospital cost savings are $3,022 per person per month (see Is Housing Health Care?). Over the past few years, health insurers have started paying more attention to issues of homelessness. Health plans like Kaiser Permanente, Blue Shield, and UPMC are making investment in housing (see The Future Of Housing Support).
So, what is the emerging model for facilitating housing when needed? What are health plans paying for? How are provider organizations making the numbers work? For more, I reached out to OPEN MINDS Chief Operating Officer Stacy DiStefano, who noted:
Pure and simple, safe and stable housing is essential to health care. There can be no home- and community-based services (HCBS) without the home. In the complex care space, consumers face a higher hurdle to affordable permanent housing due to factors such as lack of credit history, low income, and stigma. What we’re seeing is not that health plans are directly paying for rent or mortgages, but rather, health plans are paying for “housing-related activities and services” to keep consumers successfully anchored in the community and out of institutions (see Coverage of Housing-Related Activities and Services for Individuals with Disabilities).
These “covered” supports include housing transition services (direct support for consumers with disabilities or chronic homelessness to help transition them into stable housing; developing individualized housing support plans, identifying resources to cover housing-related expenses; ensuring that living conditions are safe, etc.) and tenancy support services (supporting consumers to maintain housing; this includes education, training, and coaching on the roles of tenants and landlords, linking to community resources to prevent eviction, etc.)—as well as wraparound physical health services.
While we’ve seen a version of this type of service model for years with ACT teams, a more innovative version links not only the soft skills of housing permanency, but an integrated care model that bridges to natural supports in the community. For provider organizations, the opportunity is to offer health plans the “package” of forward thinking supported housing services. This means accepting a percentage of the consumer’s available income for the rental payment while creating a service line on the in-home health care and tenancy-related supports; braiding in physical health care; intentional community integration; as well as seeking non-traditional local partners such as animal adoption for companionship, chain department stores for home items, and local private employers. A whole package approach to sustained community integration can offer new solutions to an old problem.
The housing issue is one of the most fundamental social determinants of health and represents another important piece of “whole person care”—particularly consumers with complex support needs. We can expect to see more innovation in creative approaches to blending and braiding housing and health care dollars. For more resources related to housing issues and serving the homeless population, see these resources in the OPEN MINDS Circle Library:
- The Future Of Housing Support
- The Number Of People Experiencing Homelessness Increased 1% Between 2016 & 2017
- Housing Is Health Care-The Services For The UnderServed Model
- Making The Health Care Social Service Link: The Community Care Behavioral Health Care Study
- Homeless Rate Nearly 10 Times Higher For Former Prisoners
- Only 20% Of Older Homeless Adults Have Advance Care Planning
- 10% Of Young Adults Experience Homelessness Each Year
- Rise In Proportion Of Head Start Children Who Are Homeless; Now Over 4%
To learn more about the federal system for supporting the homeless population, check out U.S. Spending On Housing Assistance Programs: $44.7 Billion In 2016. This report provides an overview of federal housing assistance programs, participation in these programs, and trends over time. And stay tuned as we continue to cover this issue.