The healthcare system is uniquely positioned to see how the social safety net can fail people who are homeless and who often suffer from substance use disorders and severe mental illness.
• Homeless people end up in emergency rooms when they fail to find community help for their chronic illnesses.
• Housing First is a national model that focuses on finding housing for homeless individuals and helping them obtain healthcare and other services.
• Bergen County, New Jersey, is the first place in the United States to end homelessness, and the University of Illinois Hospital and Health Sciences System is one of the first hospitals to find housing for homeless patients.
Communities nationwide cope with homeless populations and their multiple behavioral, mental, and physical health issues. Hospitals and outpatient providers often see these patients when they are at their worst medically, but until recently, they have not been involved in helping homeless people find housing.
That is changing, starting in cities like Chicago, where homeless patients return to hospitals and EDs so frequently that nurses know some of them by name.
“A risk factor for being homeless is the number of times a person comes into the emergency room,” says Stephen Brown, MSW, LCSW, director of preventive emergency medicine at University of Illinois Hospital and Health Sciences System.
“We had one person who came in 140 times in a year,” he says. The visits stopped only after the patient was struck and killed in a vehicle-pedestrian accident, he adds.
One of the reasons so many homeless people end up in EDs is because there are not enough community services to help them with medical, behavioral health, and mental health needs. “The failure of other systems means the cost is shifted into healthcare,” Brown explains.
A novel solution is for health systems to use some of their own resources to find homes for their homeless patients. It is part of the national Housing First model, in which healthcare providers and community organizations focus first on finding people homes, followed by helping them with their medical and other issues. (See story on Housing First in the February 2018 issue of Case Management Advisor.)
The University of Illinois Hospital and Health Sciences System, along with other health systems, local nonprofit organizations, and governmental agencies, developed the Better Health Through Housing program that helps homeless individuals find permanent housing as they stabilize their health. So far, the outcomes are positive with reductions in ED visits, hospitalizations, and costs.
ED visits dropped 57% and hospitalizations declined 67% among people in the housing program. The program also saw a 21% reduction in healthcare utilization costs related to the University of Illinois Hospital — but not including other hospitals, Brown says.
“On the survey, many individuals reported going to between two and five different emergency rooms, but we were only able to capture our healthcare costs,” he explains. “It’s very difficult to get claims data in the state.”
In other communities, initiatives to end the problem of homelessness have begun with governmental and nonprofit agencies in collaboration with healthcare providers.
For example, Bergen County in New Jersey is the first community in the nation to have ended chronic homelessness, according to the U.S. Department of Housing and Urban Development. (More information can be found at: http://bit.ly/2JMbSpt.)
“We’ve been very successful because of a number of reasons,” says Julia Orlando, CRC, EdM, MA, director of the Bergen County Housing, Health, and Human Services Center in Hackensack, NJ.
The housing center is a collaborative effort by governmental agencies, faith-based organizations, and nonprofits. They follow a Housing First model, with a focus on healthcare and everything else from legal help to free meals that a homeless person might need, she says.
“We’re a one-stop location where people can get meals, shelter, access to healthcare, and — most importantly — access to housing,” Orlando explains. “All the different agencies that intersect with this work have one place in which they can do it together.”
The 25,000-square-foot facility employs onsite nurses and legal aid services. For the past two years, the center has helped Bergen County sustain functional zero in chronic homelessness — defined as when the number of homeless patients does not outpace the monthly housing placement rate — including for veterans, Orlando says.
The center found permanent housing for about 1,300 people. There is a 90-day emergency shelter, and center staff work quickly to come up with a permanent housing plan for each person in the shelter.
“Everything we do is focused on getting people back into housing,” Orlando says.
“Our relationship with local hospitals and providers has evolved over the years,” she adds. “There’s a high need for substance use treatment, and mental healthcare also is a big need among this population.”
Chronically homeless people often have neglected their medical needs for years, ignoring symptoms of diabetes and other chronic illnesses. When they are very sick, they visit the ED and improve enough to return to the streets.
“They use the ER quite frequently, and one of our goals was to stop the overuse of ERs,” Orlando says. “By having nurses onsite and making sure everyone coming in has had an evaluation, the nurses are then able to connect people to primary care so they can rely less on emergency services.”
As an ED social worker 14 years ago, Brown was struck by how many patients with severe mental illness and homelessness came through the doors. “There was no systemic approach to handling these cases, and many of these individuals were what we now deem superutilizers of emergency medicine.”
A recent study of homeless adults who repeatedly visited the ED found that they reported comorbid psychiatric, substance use, and medical conditions, as well as high levels of pain. The study also found that a social work case management intervention helped this population become more stable and resulted in their using ED alternatives.1
Brown was an early believer in the concept of identifying structural issues that prevent people from getting necessary medical help and fixing these through case management strategies.
“In emergency medicine, there is a lot of burnout because staff is overwhelmed with the number of patients coming in all the time,” Brown notes. “And one definition of burnout is feeling powerless to change things that would impact patients’ lives.”
It took another decade before Brown was able to turn his idea of tackling homelessness to improve homeless patients’ health into a funded plan, based on the Housing First model.
The University of Illinois Hospital and Health Sciences System partnered with the Center for Housing and Health in Chicago to start a pilot program targeting the chronically homeless population. (See story in this issue on how homeless agency/healthcare provider collaborations work.)
The program started in November 2015 and has placed more than 55 individuals in supportive housing, Brown says.
“We’ve been tracking their outcomes, too,” he adds.
About 47% of people who are placed in homes have stayed there, a percentage that seems low but could be related to the population’s high rate of multiple conditions, including mental illness, which impacted nearly three out of four people in the program’s first cohort.2
“Two of the individuals qualified to be institutionalized,” Brown says. “We tried to move one person into permanent housing, but she was too acutely mentally ill, untreated, and now she’s in a state mental hospital.”
The program has continued since its initial grant, using $300,000 in hospital funding.
“We have had three cohorts, each based on the fiscal year in which funding came through,” Brown says. “In our first cohort, 26 individuals were placed in housing, and the mortality rate was 30% — very high, very disturbing.”
This cohort’s comorbidities included the following:
• 77% with substance use disorder;
• 77% with hypertension;
• 57% with asthma/COPD;
• 42% with cancer;
• 23% with diabetes;
• 23% with heart failure;
• 19% with metastatic cancer;
• 19% with HIV.2
“It was stunning the amount of comorbidities we saw in the first cohort,” Brown says. “We’re just now coming to terms with the severity of mental illness in individuals in our program.”
These very sick, homeless patients need housing alignment and support, he says.
From the population health perspective, the housing focus makes sound economic sense, he notes.
“One emergency room visit is more expensive than putting someone up in a luxury hotel,” Brown says.
1. Moore M, Conrick KM, Reddy A, et al. From their perspectives: the connection between life stressors and health care service use patterns of homeless frequent users of the emergency department. Health Soc Work. 2019;Epub ahead of print.
2. Brown S. Better health through housing, a healthcare & housing collaborative: Lessons Learned. Research presented at the Community and Global Health Honors Program, March 12, 2019, Loyola University Medical Center, Maywood Illinois.