What are the connections between policymakers’ decisions, homelessness, and health? A new research analysis in the February issue of Health Affairs suggests that there are significant correlations. Researchers Cheyenne Garcia, B.A., Kelly Doran, M.D., M.H.S., and Margot Kushel, M.D., explore factors leading to homelessness, the relationship between homelessness and health outcomes, and policy innovations to address these issues.
The researchers report that unsheltered homelessness has increased by 30 percent since 2014. With homelessness, there is a disconnection from healthcare services and a higher number of people experiencing substance abuse, mental health disorders, exposure to the elements, and risks such as violence. Additionally, there is a nationwide trend that the homeless population is aging and, with it, premature onset of chronic medical conditions.
Homelessness is harmful to health, and poor health increases the risk of homelessness, Kushel says in a linked video statement, who is a professor of medicine at UCSF and director of the Benioff Homelessness and Housing Initiative, “People experiencing homelessness have limited access to longitudinal care, increased reliance on the Emergency Department (ED), and increased rates of hospitalization and mortality.” “Inadequate access to affordable housing can lead to housing insecurity, which causes stress and material hardship, both of which can lead to adverse health outcomes. Conversely, poor health can result in high medical bills and lost income, thereby leading to housing insecurity,” the authors report. Health systems can change health outcomes for vulnerable populations by providing improved access to care, offering on-site social services, screening for homelessness, and providing referrals for homeless services, Kushel adds.
The authors point out that the unhoused population has a lower use of non-ED ambulatory care and a higher use of ED care and hospitalizations compared to the housed population. Additionally, the average length of stay at hospitals, as well as the rates of readmission, is higher for the unhoused population. A higher percentage of people without housing are hospitalized for conditions related to mental health and substance use compared to the general population.
Since “the root cause of homelessness is a lack of affordable housing for extremely low-income households,” the researchers argue, “solutions to reduce homelessness must incorporate strategies to expand the availability of affordable housing and increase incomes.” They concur that solutions require action from entities other than the healthcare system. However, the research team adds, already “Health care entities have partnered with housing providers and participated in health care financing innovations to reduce homelessness.”
One change that can be implemented is low-barrier care. The authors mention that many health systems already offer this, including those that receive Health Care for the Homeless funding. Clinics such as the Homeless Patient Aligned Care Team (HPACT) clinic, offered through Veterans Affairs (VA), provide care on a walk-in basis through mobile units and telemedicine, as well as transportation assistance. They help with medication and arrange follow-ups. Reportedly, the patient experience of those who received care from HPACTs is better than those who received care from PACTSs not specifically catered to the unhoused population.
There have also been some successes with Critical Time Invention (CTI), a model developed for people experiencing homelessness and mental illness. “CTI is a stepped, time-limited intervention implemented during a transition from an institution, such as a prison or hospital, to the community,” Garcia, Doran, and Kushel write. Case management starts in the institutional setting and transitions gradually to community care.
Another method to address homelessness and improve the health of the unhoused is screening for social needs. “Screening identifies patients who could benefit from homelessness response and prevention services, so that health systems can help them connect with community resources,” the authors explain. Concerns exist that “[S]ocial needs screening may increase stigma and that health care providers lack the time or resources to act on the information gathered.” Interventions based on screening need ongoing engagement. The researchers accept that more studies are required to gauge how effective screening is in reducing homelessness.
Solutions also include medical respite, which is post-hospitalization care for people who need ongoing care, and it provides shelter to people who are homeless. Studies show that medical respite programs help reduce hospital readmissions and length-of-stay and improve housing status at discharge. “Recently, there has been increased willingness among payers, including some state Medicaid programs and managed care organizations, to reimburse respite providers for care,” the researchers report.
To further reduce homelessness, actions to make supportive housing available and increase the supply of affordable housing are required. Support for Permanent Supportive Housing (PSH) partners partnering with subsidized housing is desired. Housing First is a program that includes subsidized housing and services such as life skills training and case management. Some healthcare organizations, the authors mention, have invested in affordable housing. Medicaid Section 1115 waiver programs provide opportunities to pay for nonmedical interventions, such as housing and moving assistance. Some states have started using Medicaid funds to help people experiencing homelessness with housing support and case management.
“To protect people with complex health care needs from the crushing medical debt that depletes savings and increases the risk for homelessness, the federal government should implement policies to increase health coverage and reduce out-of-pocket health care expenses,” the researchers advise. They underscore that “health systems are uniquely positioned to play an important role in addressing homelessness and improving the health of homeless populations, as people at risk for or experiencing homelessness often have needs that precipitate engagement with the health care sector.” Intervention is vital, the authors reason. Health systems, payers, and healthcare providers should feel inspired to act, the researchers say, “[t]o limit the negative impacts of health crises on housing security and the negative impact of homelessness on health.”
