Despite national declines in homelessness, New York has continued to see a rise in its homeless levels. Lack of stable housing for homeless individuals often results in the frequent use of costly health care services and is a major driver of medical expenses. These are costs that can be avoided. A recent article published in the New England Journal of Medicine cites the lack of investments in social determinants of health, such as housing, contributes to exorbitant spending in medical care. The article makes the case that the costs of investing in innovative health interventions, like supportive housing, are largely offset by the savings generated from reduced health care utilization (Shah, Nirav R., Kelly M. Doran, and Elizabeth J. Misa. “Housing as Health Care: New York’s Boundary-Crossing Experiment.” New England Journal of Medicine (2013): 2374-77. Print).
Supportive housing combines affordable housing with support services to help people who face the most complex challenges to live with stability, autonomy and dignity. Supportive housing is targeted to individuals and families who are homeless, at risk of being homeless or institutionalized, and experience multiple barriers to independent housing. These individuals tend to cycle through institutional and emergency systems with little to no improved outcomes. Without housing, these vulnerable individuals cannot access and make effective use of vital treatment and supportive services.
New York State (NYS) is responding to the staggering costs of serving frequent users with complex needs through its Medicaid Redesign Team (MRT) Initiative. The MRT was designed to address escalating costs and quality issues in the State’s Medicaid program through the development of a comprehensive, multi-year action plan. MRT placed a premium on investing in supportive housing as a critical component to achieving the “Triple Aim” of better health, quality care, and lower costs for traditionally underserved populations. In order to improve health outcomes and contain costs, state and local policies must ensure that an individual’s housing needs are also met. New York has also implemented Medicaid Health Homes – community-based provider networks that coordinate and manage the provision of medical, behavioral and social services, including housing, for this high-need, frequent user population. The MRT established the Supportive Housing Initiative to fund new supportive housing through capital investments, rental subsidies and service supports. One of the most pressing issues facing the Initiative is bringing supportive housing to scale for this high cost/ need population. The need for housing units, particularly in New York City, far exceeds the supply and even with crucial investments in capital by the State, there still remains a critical gap.
In this article, we describe the obstacles Health Homes in the Bronx face working with homeless and unstably housed clients, and provide policy and systems change recommendations for strengthening the housing system to meet their needs.
The Bronx Health and Housing Consortium, with assistance from the CSH, collected and analyzed data between December 2013 – January 2014 concerning the obstacles facing Health Home service providers in the Bronx in obtaining housing for their clients. At the annual Bronx Health & Housing Consortium meeting in December 2013, the four Bronx Health Homes reported the percentage of enrollees who answered “Yes” to the NYS Assessment form question: “Are you Homeless?”
As of December 2013, an average of 21% of Bronx Health Home clients were self-reported homeless. At the same Consortium meeting, the NYS Department of Health reported 7,743 people enrolled in Bronx Health Homes. Thus, 21% of 7,743 translates to 1,626 Bronx Health Home participants homeless or unstably housed. Even if the actual need for units is half this figure, there would still be a need for almost 800 units in the Bronx for Health Home participants. Last year, there were about 50 MRT permanent supportive housing units allocated to the Bronx, all scatter-site and for single adults.
We also asked the Health Homes to supply the following data from this sample that identified as homeless: demographics, entitlements, medical diagnoses, service utilization and housing situation. This second data source, which includes information on 428 Health Home enrollees, was collected from three of the four Bronx Health Homes. All of this self-reported data is included in the assessments performed by case managers at the Health Homes. Our final source of data is a select qualitative sample comprised of thirteen case studies completed by Health Home care coordinators. Here, care coordinators were asked to select cases that they believed highlighted the obstacles that they face in their attempts to acquire stable housing for their clients. We use this data to illustrate the work required on the part of care coordinators to support Health Home enrollees with complex needs. All three sets of data were made anonymous before our review.
Our study found that the Health Home population is both medically frail and facing precarious housing situations. Our demographic snapshot indicates that Health Home enrollees are a diverse group, with varying and complex needs that are not currently being met. The median age of our Health Home enrollee is 48 years old, and 20% of our sample is over the age of 60. While much of the MRT housing in the Bronx, and a substantial portion of NY/NYIII housing (NY/NYIII is a New York City supportive housing initiative), is intended for single adult occupancy, our study sample size found that 28% of the participants are not single: 15% have minor children, 4% live with children over the age of 18, and 9% live with their partner in childless, 2-adult households.
Their living arrangements are often unstable. Thirty percent (30%) live with friends or family; 28% live independently in rental apartments but are at risk of eviction; 23% live in shelters; 7% live in houses referred to as ¾ housing; 6% live in SROs; 3% live in public housing; 2% live in residential facilities, and 2% are homeless living on the street.
The qualitative case studies demonstrate that for those who do experience unstable housing conditions or homelessness, care coordinators face numerous obstacles in attempting to find them more stable housing. Care coordinators report that:
- Clients living with friends or family are at risk of being asked to move out, or are living in untenable physical conditions;
- In some cases, clients have been on the New York City Housing Authority waiting lists for 2-3 years;
- Supportive housing eligibility requirements are so narrow that clients do not qualify
- In attempting to find housing for their clients, they often go to great lengths, including one case where a worker made 300 contacts with various agencies and housing providers over the course of one year.
Health Home participants have serious housing needs. One-fifth of all Bronx Health Home participants are unstably housed/homeless. This need is not currently being met by MRT, NY/NY III or any other source of affordable housing. While the present study has several limitations including the sample size and the self-reported data source, the study does find some compelling evidence for bringing housing to scale for some of the state’s most vulnerable people. Below is a summary of a few of the challenges identified from the Bronx Health Home study:
Challenge #1: Scarce affordable housing options for individuals with fixed incomes and special needs.
Recommendations: New affordable housing must include units that are accessible to physically disabled participants and supportive housing for the aging to keep them out of costly nursing and adult homes. Broader housing eligibility criteria are needed for high need frequent users of health and other public resources (public assistance, criminal justice, shelter, etc.). Future affordable housing endeavors such as new MRT initiatives, a new NY/NY agreement and Mayor DeBlasio’s affordable housing initiative should target individuals in this high utilizing category.
Challenge #2: Lack of diversity in unit sizes offered, along with narrow eligibility criteria. This leaves clients ineligible for housing or relegated to long waiting lists.
Recommendation: Increase capital investment for housing and incentivize the creation of larger units so that families as well as single adults can access housing
Challenge #3: Care Coordinators have limited time and resources to dedicate towards finding housing.
Recommendations: Sufficient training on Health Homes and housing integration and where possible, funding for housing specialists to serve as intermediaries should be provided. Lastly, a centralized (state/ citywide) coordinated assessment and referral (or placement) system is needed to identify and prioritize frequent users and coordinate their intake, assessment and provision of housing referrals to ensure the right person is getting into the right bed in a timely manner.
Research has well-documented the inextricable link between housing and health. Health Homes are not able to fully address the health needs of their high-need frequent user participants, nor are policymakers able to reap the full benefits of this innovative coordinated care approach, until high-need individuals are living in stable, suitable conditions.