She had seen it in the movies a long time ago. She was sure it wouldn’t work, but at this point, she didn’t have much else to hang her hopes on. She was tired, cold, and hungry. She looked down. They weren’t ruby red and they certainly couldn’t pass as elegant heels, but despite all of that, she clicked her boots three times, and only changed the words slightly. “There is no place like home. I wish I had a home. I wish I had a home.”
Samantha Kiley, MPH, MBA
This imaginary scene could take place in cities and towns across the country. Many individuals and communities face the daunting issue of homelessness and housing insecurity. In Atlantic City, NJ, AtlantiCare has long experienced and addressed the devastating impacts that not having a home can have on the emotional and physical well-being of individuals and society.
Patients without homes often seek shelter and food in its Emergency departments. They seek often seek care in this hospital setting for preventable or worsening chronic conditions. If these housing-insecure patients are admitted, their discharge planning and follow-up care becomes a challenge.
In addition to physical medical concerns, housing-insecure individuals often face behavioral health challenges as a result of years of traumas they experienced by living in an unsafe environment. They are at high-risk for substance use disorder. They are often isolated from family and society in general because of the stigmas they so wrongly face. They might not reach out for help. In fact, as a result of being homeless, they might not have access to a phone, computer and other basic communications tools. This makes it challenging for them to reach out for help and for healthcare providers to keep in touch with them. This isolation can lead to worsening depression and anxiety.
Recognizing this, AtlantiCare’s Federally Qualified Health Center team focuses on going out into the community to identify at-risk individuals. These individuals might be on the street. They could be in a public transportation center. They might be staying with a friend.
In addition to impacting patients’ well-being, housing concerns can also impact a healthcare system’s workforce. With a hospital in an urban setting, recruiting staff can be a challenge if those individuals don’t have access to affordable, stable housing.
AtlantiCare continues to share and learn best practices for improving the housing and solving for the lack of housing in the local community it serves. It has tasked an internal steering committee to oversee and advise this process. Individuals representing various aspects of the organization, including case management, behavioral health, government relations, clinic services, finance, community benefit and real estate are meeting and creating a blueprint which outlines available resources, stated community needs and service gaps. The blueprint also recommends potential solutions for which the organization is interested in playing a role. These plans require creativity, grit, and an intentional commitment to focusing on short-term solutions to address immediate needs, and longer-term systemic approaches to eliminating the root causes of housing insecurity.
AtlantiCare’s 2019 Community Health Needs Assessment showed affordable housing is essential to establishing financial security and a sense of place.
Housing insecurity causes barriers to social and civic interventions that are a critical part of an extended care plan for these individuals. AtlantiCare has found that the more complex the care needs are for individuals or populations, the more critical the need is for collaboration across many sectors.
In addition to its internal efforts, the organization is reestablishing its relationships with its long-time community partners who play an important role in this work, with a renewed focus on outcomes and results.
Three priority areas are part of the plan. These include transitional housing, affordable housing/ homeownership, and housing stock. All three of these components are essential as we work with the community to develop a comprehensive plan to ensure that all have a safe and affordable place to call home.
Transitional housing is essential in supporting patients who need continued care and navigation. They are often unable to achieve the goals of their care plan due the fact that they do not have a place to call home. Transitional housing follows the Housing First model (National Alliance to End Homelessness, 2016) that many housing and social service groups have adopted. It’s the notion that if we, as caregivers, assist in establishing a roof over one’s head, first, we can then continue to plan and administer services to individuals.
Hospitals and healthcare systems can certainly play a role in supporting the establishment of transitional housing sites in their communities. This approach assists in helping patients get the right care timely and in the most appropriate setting. It drives down uncompensated medical care and most importantly, establishes the patient’s personal journey to self-sufficiency. Transitional housing can be a win-win for healthcare systems and patients. Key is aligning collaborative work across sectors. Public, private, non-profit, healthcare, social services, and other organizations can, and should, support this work.
Once we restore individuals, we need to enable them to affordably reside – and even better – to own their own home. Too many Americans spend too much of their income on housing-related costs. It is recommended that the average American spend no more than thirty percent of their income on housing related costs (C. Herbert et al, 2018). Housing developments that create low-to-moderate-income units assist in enabling residents achieve this goal. Down payment initiatives can assist in transitioning renters into homeowners, removing variable rents. They add a sense of stability and safety to a neighborhood when the residential population remains consistent year over year. AtlantiCare is exploring supporting innovative ways to invest in housing initiatives aimed at supporting low-to-moderate income families. As part of this effort, it will soon launch a Down Payment Assistance program with its workforce to incentivize homeownership in select communities, including Atlantic City.
Finally, housing stock will be the third prong of our effort. There is a limited supply of high-quality housing stock in our community. Poor housing conditions can lead to respiratory diseases, including asthma, and can be a source of unintended injuries. While we are assisting patients with temporary placements; providing them the incentives and removing barriers to affordably rent and own a home, we also need to make sure that the homes our workforce and patients live in don’t detract from their overall health. Because of this, investing in refurbishing existing and/or adding high-quality housing stock are equally as important.
Partnerships are needed to garner the funds necessary to advance these efforts. Healthcare systems are natural partners in accomplishing this work, as they continue to expand the definition of health, enter into risk-based contracts, and work to address the social determinants of health (P. Bailey, 2020). Multi-sector initiatives, which include physical and behavioral healthcare, community development, housing, and social services, can unify the parties around the common goal of ensuring the health of the whole individual. This whole individual approach should include their having a place to call home. Initiatives like these have promise for continued community transformation and improved overall quality of life. Something we all aspire to achieve as we continue life’s journey down the yellow brick road, called life.
Samantha Kiley, MPH, MBA, is Executive Director of Community Health Advancement & Development at AtlantiCare.
