As Public Health thought leaders push for greater understanding of the social determinants of health, they increasingly focus on stable, affordable housing as a critical piece of the puzzle for reducing the risk of worsening chronic health conditions, frequent and/or avoidable hospitalization, increased costs, and early mortality for vulnerable populations. Kaiser-Permanente Chief Community Health Officer Bechara Choucair and National Health Care for the Homeless Council CEO Bobby Watts persuasively argue in Rx for Health: A Place to Call Home that “homelessness itself can accurately be characterized as a dangerous health condition.” The statistics they cite demonstrating dramatic health outcome and mortality disparities for people experiencing homelessness strongly suggest that increasing access to safe and secure housing would, at a population health level, have an enormous impact.  Simply stated, preventing people from losing their housing in the first place also prevents poor health outcomes. In turn, re-housing people who have become homeless reduces the danger of rapidly deteriorating health that is part and parcel of homelessness. Yet there are thousands upon thousands of people across the U.S. whose unmanaged chronic conditions have already been exacerbated by homelessness. Effectively and sustainably addressing their needs entails grappling with an array of policy and operational challenges.
A safe place to call home represents a necessary but not sufficient intervention for many of the people who are at the greatest risk. Stable housing undeniably generates huge advantages in preventing and managing chronic conditions—from medication storage to freeing up the time and energy needed to focus on recovery and follow-up care to reducing stress to avoiding infectious diseases that readily spread when people lack access to adequate hygiene facilities. On the other hand, the individuals with the greatest barriers to managing their health often need more than a roof over their head in order to turn the corner in stabilizing and recovering.
In Seattle, both the aging of the homeless population and Coordinated Entry protocols that prioritize people with chronic behavioral health conditions for scarce supportive housing units have brought this challenge into sharp focus. In recent years housing agencies there have seen dramatic increases in admission of people needing intensive health care supports.  Especially those who have experienced chronic homelessness exhibit a high incidence of complex health and social needs requiring intensive clinical and care management supports. People in this group are also highly susceptible to acute health issues that require interventions that many housing agencies are typically not equipped to handle.
A Path Forward
The growing national trend toward partnerships leveraging the expertise and other resources of supportive housing agencies, health care payors, hospitals, and others provides a platform for innovation in integrating housing supports and health services. Including outpatient health care providers in these collaborative models can result in much improved coordination of health care. Primary care, chronic care management and education, behavioral health treatment, and even intensive recuperative care have all been successfully integrated with more typical housing supports such as stabilization assistance and milieu management. To the extent that these new housing-health models bring health services to the buildings where the neediest clients reside, incorporate outreach work, integrate case conferencing, and employ other methods of increasing access and reducing barriers, they can significantly reduce avoidable first responder calls, ER visits, and inpatient admissions while increasing resident resiliency and quality of life.
Seattle-King County Health Care for the Homeless Network’s Housing-Health Outreach Team (HHOT) provides just one example. HHOT nurses and behavioral health mid-levels, supported by mobile medical providers, not only set up shop at supportive housing buildings, but function as an integral part of the buildings’ case management teams and supportive services infrastructure. A City of Seattle Fire Department analysis indicated that HHOT accounts for a significant depression of calls to 9-1-1 from these buildings. Moreover, the Health Care for the Homeless Network documented a high rate of follow-up on chronic disease management plans and a very high housing retention rate for HHOT clients. 
Overcoming Barriers to Sustainable Housing-Health Partnerships
Hitting the sweet spot in meeting the health services needs of the most marginalized and vulnerable residents requires intensive cross-sector education and support for service teams comprised of staff from multiple agencies and different organizational cultures. Leaders on all sides must navigate uncharted territory around everything from their partners’ strategic and financial drivers to their jargon to their compliance issues.
In addition, in Washington and likely in other states, bringing innovative models to scale will require Medicaid policy changes. Consider Washington Medicaid’s recent foray into contracting with supportive housing agencies as a more affordable assisted living alternative for members with intensive needs related to chronic behavioral health or other disabling conditions. This contracting falls under Washington’s Foundational Community Supports (FCS) program, which is part of Washington’s Medicaid 1115 waiver package. By funding the expansion of certain housing stabilization supports as people who meet certain diagnostic and other criteria enter supportive housing it provides welcome additional capacity. Yet FCS does not support actual health care services; meanwhile supportive housing agencies and their partners frequently struggle to recoup even a fraction of their costs of providing onsite health care services through Medicaid billing. Given the very high rate of Medicaid enrollment among building residents, this disconnect inhibits the spread of successful innovation.
Other complex partnership challenges have emerged as supportive housing agencies, managed care organizations (MCOs), and, in some cases, hospitals have begun exploring partnerships to reduce the risk of hospitalization and hospital re-admissions for MCO-members who are eligible for or are already residing in supportive housing. A partial list of the complicated administrative, operational, and financial questions that may complicate the process of collaborating effectively includes the following:
- When more than one MCO covers residents in a given supportive housing program, will a given MCO invest in dedicated health care services and care management supports that will also benefit members of a competitor? Or will the MCOs insist on services that are solely available to its members?
- Will different MCOs require different interventions and will these interventions need to be provided by their own personnel?
- Will there be multiple authorization protocols with different forms required?
- Given the commonplace churn of Medicaid beneficiaries as they choose to move one managed care plan to another, how can MCOs be encouraged to invest in interventions that may only pay returns (in utilization reductions and cost savings) a year or more down the road?
- How does the ever-present possibility of changes to State Medicaid contract terms impact the ability of MCOs to nimbly experiment in partnership with housers and/or hospitals?
Considerable time, effort, intention, and resources are required to build mutual understanding among partners, ensure effective day-to-day collaboration among front-line staff from different agencies, advocate for needed policy change, and answer questions like those outlined above. In many cases, the use of a facilitator or other intermediary with experience and expertise in the housing, health care, Medicaid, and managed care arenas can be a critical factor for success. Some resources that I have found helpful in my work supporting the development of effective partnerships in this space include the following:
- The National Health Care for the Homeless Council (https://nhchc.org/)
- Benioff Homelessness and Housing Initiative (https://cvp.ucsf.edu/programs/benioff-homelessness-and-housing-initiative)
- Innovative Models in Health and Housing report (https://www.liifund.org/wp-content/uploads/2017/08/Health-and-Housing-LIIF-Mercy-Report-2017.pdf)
- Center for Health and Housing (https://housingforhealth.org/)
- Corporation for Supportive Housing (https://www.csh.org/)
- As cited by Choucair and Watts, the average life expectancy for a person without stable housing is 27.3 years less than the average housed person. People between the ages of 25 and 44 experiencing homelessness face an all-cause mortality risk that is 8.9 times higher than the general population; it is 4.5 times higher for those 45 to 64. In addition, patients without housing are also much more likely to be readmitted to hospitals (50.8 percent) than others (18.7 percent), and when admitted tend to stay 2.3 days longer.