Housing: A Key to the Triple Aim Door

 

At JSI, we’ve been closely observing the shifting health care landscape and identifying promising practices and frameworks for achieving the Triple Aim (reduced per capita cost, improved experience of care, and improved population health) and whole-person care. One of the most interesting dialogues underway is how to better understand and respond to social determinants of health (SDOH). The evidence keeps growing indicating that factors outside the clinic walls such as educational opportunity and community environments play a more significant role in determining health outcomes than factors such as access to care and genetics. This has led many to contend that zip code says more about health prospects than genetic code.

From a health system perspective, there is recognition that many of the highest cost patients would be better served, and cost less, if social and clinical needs were addressed in concert. From a clinician’s perspective, there is a hunger for new approaches and tools to address circumstances outside the clinic walls that are causing and exacerbating chronic illnesses. An Robert Wood Johnson Foundation-funded survey found that the vast majority of physicians not only see social needs as just as important to address as medical conditions but wish they could write prescriptions to address those needs.

There is resistance to change and concern about a “slippery slope” down which we slide toward health systems taking over responsibility from other sectors and government. In response, there is a need to experiment and demonstrate success with well-defined initiatives for patient populations that are clearly not thriving with current approaches. When asked who fits that profile, many health system leaders, particularly from public health systems, answer: the “chronically homeless.”

Treating Homelessness

Malcolm Gladwell wrote an influential article in the New Yorker in 2006 describing a Reno native he dubbed “Million-dollar Murray,” a homeless alcoholic who ended up in ambulances, hospitals, and jails multiple times every month. The moniker came from a back-of-the-envelope estimate of Murray’s cost to public systems over a decade. Murray is far from unique. In cities and counties across the country, a small number of individuals with concurrent homelessness and substance abuse, mental health, and physical health issues rack up six-figure costs and burden public systems. On the flip side, there is growing evidence that a range of housing approaches, in particular supportive housing that pairs housing with services and care management, can effectively improve health and financial outcomes.

Are we ready to make housing part of the treatment for homeless individuals? As Dr. Josh Bamberger, Medical Director for Housing and Urban Health at the San Francisco Department of Public Health, put it,

“We provide very expensive medications to AIDS patients, for instance, without considering the cost. We have a similar treatment for people with mental illness and substance use. We know what will keep people alive. But we are hesitant to spend the money [on housing]. The kicker is that investing in housing reduces health costs.”

Emerging Efforts to Solve the Puzzle

In our new report, Integrating Housing Strategies with Health: An Opportunity to Advance Whole-Person Care in California, we review the rationale for health system investments in housing, explore the key elements of successful integration between housing and health, and share case examples from promising initiatives in three California counties. There’s no sugarcoating it, this sort of integration is an extremely challenging puzzle: federal and state regulations make it difficult to use health dollars flexibly for activities outside traditional clinic visits; effectively stabilizing and improving the health of high-utilizing chronically homeless individuals requires not just housing but staff with the experience and willingness to “do whatever it takes” to solve problems and address needs; and finding sufficient rental units is difficult, especially in hyper-competitive housing markets.

We were encouraged, however, to see that a few California counties are tackling these challenges head on and that there’s a growing recognition among health leaders that putting in the effort to develop partnerships with other sectors, such as housing, can reveal new strategies and align significant resources. The status quo is increasingly being deemed unsustainable, especially with Medicaid expansion in many states resulting in public coverage for this population, and leaders are taking more active roles in spurring innovation. As Marc Trotz, Director of Housing for Health for the Los Angeles County Department of Health Services, put it, “We either could have waited for the whole world to change and have more Section 8 funding, HUD funding, CMS funding, but that is not going to happen in a time frame that is going to meet the obvious and glaring issues that we are confronted with: thousands of extremely low-income and vulnerable people cycling through the system, and we can’t do anything for them with all of our other medical and behavioral health tools while they are still homeless. We are just throwing good money after bad, treating them repeatedly in the emergency room and acute hospital beds.”

Common Sense Resource Allocation

In the early 1960s, Dr. Jack Geiger was involved in setting up the nation’s first community health centers in the rural south. When he was questioned by regulators about his unorthodox use of federal funds to stock the center pharmacy with food, he replied, “the last time I looked in the book [the Physician’s Desk Reference], the treatment for malnutrition was food.” That sort of common sense approach is spreading as health systems are increasingly held accountable for outcomes.

The goal has to be keeping as many people as healthy as possible and if current efforts to integrate housing and health are deemed successful, that will be an important step toward a new standard operating procedure that emphasizes effective partnerships and responding precisely to the needs of the whole person.