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In his recent article “Where do you live?” Dr. Prabjoht Singh wrote about why he starts his patient visits with that simple question. He shares the anecdote of a patient who had managed her diabetes well until a recent visit to the hospital for high blood sugar. When he asked her what had happened? She’d been spreading out her doses of insulin in order to save money for rent.
Homelessness has become a defining public health issue of our time. Over half a million Americans are homeless. Nearly 85,000 of those are considered to be “chronically homeless,” meaning they’ve been continually homeless for over a year, or have experienced homelessness three times in the last four years. In terms of health economics, they’re the highest of a high-risk group: It’s well-established that these individuals live with elevated physical and behavioral health risks.
Like Dr. Singh’s patient, seemingly simple challenges like medication adherence can easily snowball into expensive emergency care episodes. The Department of Housing and Urban Development (HUD) estimates chronically homeless individuals cost anywhere from $30,000–50,000 per individual per year.
One case study has become popular over the last couple of years: The State of Utah reduced chronic homelessness by 91 percent, making the investment in part because of spiraling costs of emergency room admissions, jail visits and other indirect costs. Utah’s experiments serve as a leading example of what public health leadership at the state level can look like, from the policy minutiae of defining populations, programs, and budgets, to the shortcomings and opportunities of existing interventions, from shelters to rehab facilities.
Dr. Singh points out that the magnitude of the challenge extends far beyond healthcare, into housing and social welfare. He offers a few policy recommendations, such as giving states more flexibility to mix funding streams and program data between Medicaid and non-healthcare programs, better assessment of the health impact that housing interventions can have, and joining public and private resources locally, to make affordable, quality housing available in order to reduce hospital visits and achieve better health outcomes.
Below are a pair of quick examples of public-private collaborations happening at the local level. Both programs aim to reduce the impact of homelessness on Americans’ health — and wallets.
Private Sector, Public Health
University of Pittsburgh Medical Center (UPMC) is an integrated health system in western Pennsylvania, consisting of both a large health delivery system as well as an insurance carrier covering three million members across Medicaid, Medicare, and commercial plans. As both the payer and provider, UPMC is in a unique position to deliver a public health intervention to improve clinical outcomes and reduce costs among their homeless population.
UPMC recently published early outcomes from Cultivating Health for Success (CHFS), a joint program with HUD. CHFS designed to reduce the amount of unplanned emergency care delivered to Pittsburgh’s chronically homeless population. People receive stable housing, regular medical care, and access to social services such as transportation and food.
- During the first five years of the program, 51 of 60 participants were successfully housed
- Unplanned care decreased by 19.2 percent
- Planned visits to primary and specialty care improved, along with rates of medication adherence among participants
- The program produced an average cost savings of $6,384 for each housed participant, mainly derived from decreased hospitalizations and emergency department visits
Beyond these outcomes, UPMC stressed the complexity of this population’s behavioral health care needs, pointing out that, just like with us, insurance claims data doesn’t nearly begin to capture the complexity of homeless people’s health. The report also points out that while UPMC was able to generate substantial cost-savings per person, these have not yet offset the costs of implementing the program, essentially due to a learning curve of dealing with patients’ needs efficiently but holistically.
Lessons from the Bronx
New York City is one of the largest cities on earth, with an estimated population of nearly 8.5 million. NYC is also in the midst of the worst stretch of homelessness since the Great Depression in the 1930’s. This also happens to be where Dr. Singh practices medicine (in East Harlem), and it’s one of the biggest opportunities to improve public housing for underserved populations.
The SBH Health System is in the Bronx, a borough where nearly half the residents are enrolled in Medicaid and nearly a third are living in poverty. The county has also been voted the unhealthiest county in New York for seven years running, in large part because of the social and economic factors at play. It is one of the worst places in the country for drug addiction. While the transition to value-based care in the broader healthcare system — such as curbing payments for readmissions — is well intentioned, it holds some serious implications for hospitals in areas like the Bronx.
This is why SBH has partnered with the State of New York, New York City, and real estate developers to construct a mixed-use building to provide affordable housing and access to health care and social services. There will be a dedicated block of rooms for high-utilizing Medicaid patients, and the facility will include counseling, primary care, radiology services, a women’s center, pediatric care, a pharmacy, healthy food options, and a rooftop garden.
The building is still in development, with plans to open in 2018. The funding is coming from an array of public and private organizations, including local housing authorities, the state Medicaid agency, district government, and banks. Like UPMC, this effort is not just about taxes — it’s equal parts private sector investment in community health and public sector re-structuring to meet the evolving needs of the population’s health.
A New Public Health Frontier
Will SBH’s new building be enough to stem the tide of drug addiction, homelessness, and avoidable health care emergencies in the Bronx? Will urban centers like Pittsburgh, or Chicago, or Seattle, or San Francisco be able to reverse health care costs by providing housing to those who need it?
In all likelihood, probably not — at least, not this year or the next. But if this public health hypothesis plays out as expected, none of this will have been a wasted effort in the long haul. Today’s interventions are shaped and guided by real-world evidence on what works best and why.
Like any effort to introduce sustained systemic change, this won’t be quick and it won’t be easy. The challenges are numerous and well documented; treating deep behavioral diseases in a population that is not easy to work with. Programmatically, finding the right resources and talent. At the practical level, convincing economic skeptics, finding political will at a time of historic governmental turmoil, and reversing deeply held cultural views will be tough — no two ways about it.
That is why these efforts are so important. If and when they add up to build a compelling case to end homelessness, all of society stands to benefit. As Dr. Singh points out, in the status quo, instead of helping patients with a few hundred bucks to make their rent, procure basic heating, or meet their families’ nutritional needs, we are paying “many more tens of thousands of dollars in needless emergency room visits and hospitalizations that feed into a downward cycle of poor physical and mental health.”
There are too many out there for whom homelessness is a major driver of poor health. There are thousands of Americans — patients, mothers and fathers, children, and veterans who don’t need to die, but do. It’s slowly becoming clear that when we let our fellow citizens remain exposed to the disease, violence, and addiction that comes from living on the streets, we are also exposing ourselves to the deep-rooted costs of dealing with those afflictions.
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Note: This was researched in collaboration with Onboard Health, an organization dedicated to cultivating diverse talent for sustainable public health innovation.
Previously published on Tincture.io and is republished here with the permission of the author.
This was a great read. Thanks Naveen!