Opinion--Rx: Home

By Daniel Malone

Implementation of the Affordable Care Act (ACA) offers new opportunities to integrate health care, public health, and social services. Daniel Malone, Deputy Director of DESC (formerly Downtown Emergency Service Center), gives his prescription for an effective way to use these new opportunities: supportive housing.

People concerned with homelessness have eagerly anticipated implementation of the ACA for two reasons. One reason is that in states that are expanding Medicaid programs, nearly all uninsured homeless people will be eligible. But as important as increased coverage is, the part of the ACA that really gets ending-homelessness advocates excited is the opportunity to use health-reform processes and medical-system resources to fund what homeless people really need: a home. Not a “patient-centered medical home” or a “health home,” but a home home.

Using health care sector funds to pay for housing? That sounds like an overreach by human services advocates, doesn’t it? But when housing is provided to high-needs people, housing becomes health care. Converting this knowledge into financial support for housing is not yet a reality, but policy makers and human services providers are engaged in exploration of creative ways to bring this about. Much of the conversation centers on how state Medicaid plans can be modified to make housing costs, or at least the costs of social services delivered to people in housing, eligible for Medicaid payments.

When people talk about reducing health costs, they talk about better access to care so people will use primary care services rather than crisis services. Or it’s the use of community health workers to manage chronic conditions they have in mind. But what about people whose high use of expensive services may be caused or greatly exacerbated because they are homeless? In these cases, supportive housing can be a solution.

Supportive housing targets long-term homeless adults living with addictions, untreated mental illness, and other disabilities. In particular, a type of supportive housing known as Housing First is seeing good results. Rather than trying to manage the effects of illness and disability before housing is given, Housing First ensures the homeless person gets what matters most to him or her: a decent place to live. Of course, supportive housing programs offer behavioral health care and access to other medical services, but participation in these services is voluntary.

Housing First has been met with controversy. Critics would like to see housing used as a reward for better behavior and healthy choices. But what if stable housing is what enables a person to begin to improve his or her life?

The story of “Rhonda” shows how the model works. Rhonda lives in supportive housing operated by DESC in Seattle, Washington. Rhonda has a serious mental illness and co-occurring substance use disorder. After losing a clean and sober living environment a number of years ago, she began a life on the streets. She had a frequent pattern of presenting to hospital emergency departments several times a week, or even several times a day. Most times, she would arrive extremely intoxicated and complain of a variety of medical conditions, but when medical staff attempted to help, Rhonda would grow hostile and leave.

Rhonda was offered alternative living options but rejected all of them due to treatment participation requirements. She ultimately accepted a Housing First placement, thanks to its “low demand” approach. Although her emergency room use continued for a time, with staff support she began to develop insight into what prompted her behaviors and agreed to see a psychiatrist. She uses strategies to seek informal help before calling 911, and this help is often enough to keep her from using emergency services.

Stories like Rhonda’s are supported with a strong body of research on housing interventions:

Supportive housing can be used for people who may not engage in other interventions.
Supportive housing interventions are attractive to people with aversion to treatment. People will accept housing when they would have refused a place in a social service or treatment program. These people are able to retain housing at very high rates (more than 85 percent remain for at least a year), even if their symptoms remain active.

Supportive housing can dramatically reduce crisis services costs.
When homeless people are provided with housing, their use of crisis services drops steadily. In one DESC Housing First program, University of Washington researchers documented cost avoidance of approximately $4 million in one year for a study population of 95 people.

Supportive housing improves health status.
Conventional wisdom holds that the way to get costs down among frequent emergency health care users is to shift services to primary care settings. But supportive housing can prevent injuries and health problems in the first place. Consider the story of “Clint” who often passed out on the street after consuming hand sanitizer, a product he could readily find at little or no cost. After passing out, Clint would be taken to the emergency department for treatment of cuts and bruises, as well as for the management of alcohol withdrawal symptoms. Once in housing, staff helped Clint develop a plan to avoid consuming non-beverage alcohol, and to have regular visits with social service and primary health providers. In a year’s time, Clint visited the emergency room only once.

Supportive housing works for people with criminal backgrounds and reduces their continued involvement in the criminal justice system.
More than half of homeless people with behavioral health disabilities have criminal records (most commonly, but not always, for minor offenses such as trespass), and they are often excluded from community housing opportunities. Housing First programs remove these barriers. Studies show that post-housing involvement with the criminal justice system decreases substantially.

If a new medicine came on the market that achieved these results, there would be a clamor to make it available to people who are homeless. But we already have a way to treat homelessness and its effects on health: supportive housing. Let’s use this treatment to lower costs and improve lives.

For more information on DESC or research on supportive housing, go to www.desc.org.

Author

Daniel Malone is Deputy Director of DESC.