Wellness and well-being are inextricably linked to the social and economic conditions of people’s lives. Up to 40 percent of health outcomes may be attributed to nonmedical factors like income, housing status and access to sufficient healthy food.
Individuals struggling with poverty, food insecurity, housing instability or other barriers may experience poor health outcomes, increased health care utilization and higher health care costs. Addressing these nonmedical needs can have a profound and positive impact, including longer life expectancy, healthier behaviors and better overall health.
Although 80 percent of physicians agree that patients’ social needs must be met for them to achieve maximum health, health care providers are not usually in a position to address those needs. Traditional payment models reimburse providers for medical interventions and typically do not address the social determinants of health. But recent changes across the health care system have increased hospitals’ capacity to mount social interventions. For example:
- Providers must offer comprehensive care, including social supports, to qualify as a medical home.
- Holistic patient care, including attention to social determinants of health, improves provider and patient satisfaction, which can increase reimbursement for care, improve employee retention, and build and maintain patient loyalty.
With more low- and middle-income individuals gaining insurance coverage under the Affordable Care Act, health care providers must invest in meeting the social needs that can shape the health status of these patients. Hospital and health system executives who prioritize the social determinants of health as well as focus on medical interventions will be able to position their organizations to achieve the Triple Aim of improved health, improved care and lower costs.
Housing instability and health
Housing instability is an umbrella term for the continuum between homelessness and a stable housing situation. Housing instability takes many forms: physical conditions like poor sanitation, heating and cooling; compromised structural integrity; exposure to allergens or pests; homelessness; and unstable access to housing or severe rent burden.
Some recent estimates highlight the scope of housing instability in the United States: In 2013, 7.72 million households had “worst-case housing needs,” which means they had housing expenses that far exceeded their income or they lived in severely substandard shelter. Nearly 1.5 million individuals are homeless in the United States each year.
Homelessness and having worst-case housing needs are associated with poor health and increased health care utilization. For example:
- The homeless population is aging, and older homeless adults have elevated rates of chronic health conditions like cardiovascular disease, diabetes and chronic obstructive pulmonary disease, as well as geriatric conditions such as cognitive, functional or mobility issues.
- Homeless individuals are more likely to have infectious diseases, such as pneumonia, tuberculosis and HIV, and mental health, psychotic and affective disorders. Homelessness also is associated with a shortened lifespan.
- Individuals experiencing distress related to housing unaffordability or foreclosure experience self-reported poorer health and elevated anxiety and depression. The children in these households are more likely to have developmental delays.
- Substandard housing conditions can cause or exacerbate serious health issues like asthma, which affects more than 24.6 million Americans and accounted for 1.6 million emergency department visits in 2013.
Studies show that individuals experiencing housing instability have less access to preventive health care compared with stably housed people, are more likely to delay filling prescriptions and are less likely to adhere to treatment plans. These trends may be a matter of competing priorities. When faced with limited resources, some individuals may choose to spend their money, time and energy seeking housing or other basic needs first.
At the same time, unstably housed individuals are disproportionately high utilizers of acute health care resources:
- Homeless individuals are five times more likely than nonhomeless individuals to be admitted to inpatient hospital units. They also stay in the hospital for up to four days longer, at a cost of $2,000 to $4,000 a day.
- The annual cost of homelessness-related hospitalizations of children younger than 4 was more than $238 million in 2015.
Types of housing instability and related health conditions
Related health conditions
• Total lack of shelter
• Residence in transitional or emergency shelters
• Increased rates of chronic and infectious conditions (e.g., diabetes, asthma, chronic obstructive pulmonary disease and tuberculosis)
• Mental health issues, including depression and elevated stress
• Developmental delays in children
Lack of affordable housing
• Severe rent burden
• Eviction or foreclosure
• Frequent moves
• Stress, depression and anxiety disorders
• Poor self-reported health
• Delayed or diminished access to medications and medical care
Poor housing conditions
• Structural issues
• Allergens like mold, asbestos or pests
• Chemical exposures
• Leaks or problems with insulation, heating and cooling
• Asthma or other respiratory issues
• Allergic reactions
• Lead poisoning, harm to brain development
• Other chemical or carcinogenic exposures
• Falls and other injuries due to structural issues
Source: Health Research & Educational Trust, 2017
The web of housing and health
Housing instability is not randomly distributed, and some populations are particularly vulnerable. For example, newly homeless individuals who enter the shelter system tend to come from neighborhoods with high rates of unemployment. Individuals in unstable housing situations tend to have lower education levels and more recent periods of unemployment or tenuous employment. Several types of housing instability, including eviction and foreclosure, disproportionately affect women and African-Americans.
A number of other issues intersect with housing to affect individuals’ overall health and well-being. For example, people experiencing housing instability may also experience or encounter:
- Lack of transportation.
- Limited literacy or low educational achievement.
- Cultural or linguistic barriers to care.
- Limited health literacy and difficulty maintaining complete personal health records.
- Lack of social supports.
These factors contribute to housing instability and poor health. Moreover, the causes and effects of health and housing issues are difficult to untangle from larger concerns about low income, unstable employment and other forms of social disadvantage. The relationships between factors are best understood as a web, with social and economic disadvantages contributing to and stemming from each:
- Housing instability can cause or exacerbate health conditions through exposure to hazards in the environment, lack of social supports, competing priorities, and difficulty managing chronic conditions and handling stress. Individuals who are unable to adhere to treatment plans because of lack of financial resources, lack of safe and clean places to rest or administer medication, or continued exposure to environmental hazards may get sick, stay sick or get sicker.
- Pre-existing health problems also may predate housing instability. Health conditions can interfere with employment opportunities, limiting financial stability. The financial strain of medical care also can place individuals at risk. Individuals may have difficulty obtaining or maintaining stable housing because of mental or behavioral health issues, substance use disorders, or discrimination due to disability or health status.
To ameliorate the negative effects of housing instability on health status, it is necessary to shift from a mindset that considers each individual’s health situation in isolation to a view that acknowledges broader social, political and economic factors. A view that embraces the interconnectedness of all aspects of individuals’ lives demands an equally complex response to social and health challenges.
Experts in human services and health care are beginning to converge on this concept. For example, the Department of Housing and Urban Development suggests that tackling homelessness requires a simultaneous focus on improving health and on other social issues like education, employment and intimate partner violence, while the Department of Health & Human Services acknowledges that “[chronic] health conditions can usually only be ameliorated if [individuals] have a safe, stable and secure living environment.”
The links between housing and health are clear: Individuals struggling with unsafe or unstable housing experience worse health outcomes and higher health care costs. Evidence is equally strong for the benefits of interventions to promote housing stability. Spending more time in more stable housing and eliminating housing-related stressors lead to improved health and fewer, shorter hospitalizations.
Housing stabilization also has important psychosocial impacts. The “sense of home” that comes from stable housing can strengthen individuals’ mental and emotional well-being and help them avoid risky or unhealthy behaviors. Increased stability and less frequent moves also help individuals build the social ties that are essential for physical and mental health.
The role of hospitals
Health providers are realizing they can no longer expect to heal patients through medical treatment alone. Since the broad consensus is that individuals’ social needs are central to health and well-being, hospital and health system leaders are getting involved in these types of interventions, either alone or in partnership with community organizations.
The economic benefits for hospitals can be significant, because homeless or unstably housed individuals are more likely to be uninsured, be hospitalized more frequently, have longer lengths of stay, be readmitted within 30 days and use more high-cost services. Reducing homelessness and other forms of housing instability — through case management, supportive housing (supportive services combined with housing), housing subsidies or neighborhood revitalization — improves health outcomes, connects individuals with primary care and reduces utilization. When hospital and health system executives focus their resources on housing supports and case management, the cost savings can offset the expenditures by between $9,000 and $30,000 per person per year. Reducing readmissions by improving care transitions also matters more as health care providers move toward value-based models of care.
Executives of hospitals and health systems are in a strong position to make an impact. Many hospitals and health systems already have robust community benefit departments. They understand the communities they serve, have strong ties to other medical and social organizations, and have a large community footprint. Once executives decide to get involved in promoting housing stability, they need to identify their targets and approach, based on their capacity and specific goals.
Strategies to improve housing stability and potential health impacts
Potential health impact
• Community investment and partnerships to improve economic and housing stability
• Frequent use of “anchor-organization” approach, which recognizes the role of hospitals as prominent employers and economic drivers in their communities
• Examples include community centers, jobs programs, education and affordable housing development
• Improved health outcomes through stabilized housing, employment, economic stability, social service programs and neighborhood safety
• Home safety assessments for environmental hazards
• Renovations or repairs
• Reduced risk of harmful exposures to environmental hazards
• Decreased housing costs and less instability
Medical care for the homeless
• Preventive and acute medical care for homeless or at-risk individuals
• Care typically provided at traditional medical facilities, shelters or on the street via mobile medical vans
• Reduced emergency department use and hospitalization
• Improved health outcomes
Medical respite care
• Short-term transitional housing for homeless individuals deemed well enough for hospital discharge but not well enough to return to the street or a shelter
• Case management and social service referrals
• Improved care transitions
• Reduced readmissions
Transitional or permanent supportive housing
• Affordable housing units for disabled, elderly or chronically homeless individuals and families
• Case management and supportive services
• May follow the “housing first” model, which holds that baseline housing needs must be met before individuals can benefit from other forms of treatment
• Improved mental health and increased satisfaction with quality of life
• Reduced hospitalizations, length of stay and ED visits
• Improved housing stability and substantial reduction in chronic homelessness
• Substantial health care cost savings
Source: Health Research & Educational Trust, 2017
Developing housing programs
Hospital and health system leaders should consider several steps for developing housing programs:
Identify issues, opportunities and risks. Valuable information about community needs and opportunities can come from community health needs assessments, patient demographics and health trends, and observations by management and front-line staff.
Build strategic partnerships, both inside and outside the hospital. Make sure that staff from the front line to the C-suite are on board and that the hospital is in conversation with community partners that can support or collaborate on the effort. Partners may include other health care providers; city, county or state governments; regional housing authorities; social service organizations; universities; hotels and property owners; and other community stakeholders.
Research possible interventions. Other organizations are grappling with similar issues, and there can be a great benefit to adapting successful strategies rather than starting from scratch. Even the most innovative programs will build on what came before.
Consider funding implications. Consider the costs and benefits of the program. As with any new initiative, your organization will need to develop a funding plan, particularly because return on investment may not be immediate.
Educate patients, providers and the community. Community and provider buy-in is key. Consider how you will reach the individuals who need to know about the initiative.
Evaluate and adapt. Data collection and analysis will be an important part of any new initiative. As you see what is and is not producing the desired effects, you likely will need to adjust the initiative.
On a path to better health
Leaders at hospitals and health systems are acknowledging the health impacts of housing instability and taking steps to improve their patients’ housing conditions. These actions stem from a recognition that homelessness, unsafe housing and unstable housing situations can contribute to poor physical and mental health, while interventions can counteract these effects. Leaders’ diverse responses include providing case management and supportive services, connecting individuals with community resources, identifying and resolving individuals’ home-safety issues, and providing safe and affordable housing.
Housing interventions are part of a wider recognition that addressing the social determinants of health — housing, income, employment, education and food security — is necessary for improved population health.
Excerpted, with permission, from the Health Research & Educational Trust’s Determinants of Health Series: Housing and the Role of Hospitals. To download the full guide, visit www.aha.org/housing.
Bon Secours Baltimore Health System
In the mid-1990s, administrators at Bon Secours Baltimore Health System observed that, despite a $30 million investment in hospital facilities and services, patient volumes were falling. They discovered that neighborhood conditions, including rising home vacancies and drug-related crime, were keeping patients and staff recruits away.
Realizing that basic needs must be met before individuals can thrive, the health system began to focus on addressing social factors. Bon Secours began to promote neighborhood transformation in collaboration with a steering committee of neighborhood and church leaders.
Since beginning its revitalization plan, Bon Secours has developed 729 housing units in Baltimore. The residences include housing coordinators who act as case managers in helping neighbors access health care and other services. It also leads the Crime and Grime Committee, which allows community residents to meet regularly with city officials and law enforcement to discuss their concerns. And it has created programs that provide job and financial skills training, job placement, and mentoring programs for youth, adults and ex-offenders.
In 2015, the health system served more than 78,000 people through its resource centers, parenting classes, youth outreach programs and other initiatives. Bon Secours connects these various community outreach programs to reduced readmissions for congestive heart failure, development of life skills plans by 83 individuals, 15 full-term births to parents enrolled in parenting programs, and 32 new health insurance plan enrollments.
The hospital also continues to explore innovative service and funding models, including opportunities to combine Medicaid with housing funding, designating units for elderly individuals in behavioral health programs, and opening a facility for individuals with chronic mental illness. — American Hospital Association, Health Research & Educational Trust and the Association for Community Health Improvement
Children’s Mercy Kansas City
In the 1990s, allergy, asthma and immunology providers at Children’s Mercy Kansas City noticed that medical treatment alone could not prevent children from ending up in the emergency department for asthma. The hospital began to experiment with conducting home visits to evaluate for environmental triggers, and then connecting families with community partners to resolve any problems. After these home interventions, many asthma patients’ symptoms eased, use of medication could be reduced, and these children avoided further trips to the ED.
These early successes prompted Children’s Mercy to develop what would eventually become its Healthy Home program. In 2001, the system hired a full-time environmental hygienist to systematically identify and address asthma-related hazards through home visits, patient and family education, case management, and home-based interventions and repairs.
Children’s Mercy quickly realized, however, that many children were living with other significant environmental hazards. The program developed protocols to evaluate patients’ homes comprehensively, looking for evidence of a wide range of potential health and safety risks — not only allergens and asthma triggers but also other chemical exposures, pests, lead and structural issues that might lead to injury.
Since its inception, the Healthy Home program has completed more than 750 home assessments and served more than 2,500 families. It also has conducted thousands of assessments of classrooms and schools. It regularly refers participant families to any of more than 100 community organizations that make home repairs, provide resources like appliances or bedding, and connect patients and families with additional health and social services. — American Hospital Association, Health Research & Educational Trust and the Association for Community Health Improvement
St. Joseph Health, Humboldt County
The Care Transitions Program at St. Joseph Health in rural northern California provides housing for homeless individuals who have recently been discharged from the hospital. The program got its start when St. Joseph, a part of Providence St. Joseph Health, realized homeless patients were ending up in the hospital, although they weren’t sick enough for admission. These patients weren’t strong enough to return to their unsheltered living situations and lacked other options for safe recuperation.
The hospital began funding five beds at a clean-and-sober house, a transitional living facility where individuals who agree to abstain from drugs and alcohol can reserve a bed at a low cost. Individuals without stable housing stay in the facility for up to two weeks after leaving the hospital.
During their time in the transitional housing program, patients are visited by a social worker and a nurse hired by the hospital. The team gives medical education and coaching, and provides expanded case management. Its members attend follow-up doctor visits with some clients or connect them with housing and other community resources. The team also spreads the word about services in the community and the hospital.
Within its first few years, the program led to a significant reduction in readmission rates and length of stay among the population served. The return on investment was so significant that the program has since been fully folded into the hospital’s operational budget.
In addition, several clients have gone on to access other transitional housing resources, such as nonrespite, clean-and-sober-living facilities, while developing a longer-term recovery plan. — American Hospital Association, Health Research & Educational Trust and the Association for Community Health Improvement
To view additional resources on housing and other social determinants of health, visit www.hret.org/sdoh.