InvisALERT Solutions – ObservSMART

The Housing Prescription

The Housing @ Risk Program, under the leadership of Peter Semczuk, DDS, MPH, Senior Vice President & Executive Director, Moses Campus, Montefiore Health System, began in 2009 and is designed to provide coordinated health and housing support to a vulnerable population in the Bronx. This is a hospital-based, multi-discipline program that identifies people who are unstably housed and uses a range of interventions to support them. This effort is based on the fact that housing is a demonstrable social determinant of health and therefore Montefiore cannot effectively support people’s healthcare while they are experiencing housing insecurity. This is particularly challenging for the population with behavioral health needs.

The H@R team is composed of a Social Work Assistant Director, a Program Manager, a Social Worker and a part-time consultant whose goal is to help these patients find stable housing and address their health care needs. Although the team is small, its impact is wide. It provides direct services to patients, and educates nurses, physicians, navigators, social workers and others, about housing assessment and interventions. Outside Montefiore, the team works with a variety of community-based organizations, including the Bronx Health & Housing Consortium and BronxWorks, to effectively support unstably housed patients. These contacts have been invaluable in adding to the quantity and quality of available interventions, improving overall patient care and outcomes. The H@R program has several key components:

  1. In 2009, an automated alert system was created to identify patients in the Emergency Department (ED) who may be unstably housed. It notifies ED social workers to create an onsite intervention and inform the clinicians if necessary, about how a patient’s housing status may affect their care. A similar alert was triggered when these patients are admitted or discharged in order to support interventions at every stage of hospitalization. Priority was given to patients with high health service utilization to address avoidable ED and inpatient services, often due to their housing situation.
  2. The Team also accepts direct referrals from social workers and others throughout the hospital and some ambulatory settings. Having a team to refer patients with serious housing and health issues has been helpful to staff who may have time limitations and do not have the skillset to understand and support patients with a variety of housing issues. The H@R team accepts cases that require immediate action (e.g. someone is being evicted soon), involve high utilizers, and/or involve patients with high clinical needs (e.g. without an address one cannot get a transplant). They have created an Intensive Case Management system to support these patients, including representation during eviction proceedings in Housing Court.
  3. H@R staff educates social work staff, nurses and others about how to identify and support people who are unstably housed. They contribute to various other hospital committees and bring that expertise to every table.
  4. The Team participates in internal and external case conferences.
  5. A system called ‘Closing the Loop’ has been developed with external providers to facilitate follow up community care for people who are unstably housed.
  6. The H@R Team focuses on people with immediate housing needs and high health service utilization. They addressed 122 cases that were active in 2016. Half of the patients were women and the age range was 21-76, with a median age of 51.

The majority of the people served have behavioral health diagnoses, as well as medical diagnoses. The Team’s work with unstably housed people with behavioral health diagnoses can be illustrated using these cases.

Patient 1 is a homeless patient who was successfully housed, but continues to require support to remain housed and prevent avoidable ED visits and admissions. She is a 28-year-old transgender female with a history of schizophrenia, hypertension, bipolar disease, asthma and poly-substance abuse.

Housing Situation: Prior to working with the Housing @ Risk Team, she was in the Moses ED almost daily. Her last admission was in 2013. The team worked to house her in SUS (Service for the Underserved), Medicaid Redesign Team supportive housing and was successful in 2013. She has been living in supportive housing since then.

Her situation remains precarious when the rent is not paid, often due to missing appointments with Public Assistance, located in Brooklyn. She then faces eviction proceedings.

Income: Prior to working with the H@R team her income was derived from being a sex worker. She now receives Public Assistance and has an upcoming hearing for SSI in 2017.

Interventions: This patient requires ongoing support to remain housed and relatively healthy. She was an active, open case for the Team from 6/14-7/16, or 753 days. She receives support from the H@R Team in a variety of ways. For example, in 2016 when her Public Assistance case was closed, someone from the Team needed to accompany her to the Brooklyn Public Assistance office. This is often an all-day process which is why many patients lose benefits. When she was not well, the Team managed to reschedule the appointment which required many phone calls. She also required an escort to apply for and receive Food Stamps and rental assistance from HRA. Additionally, she was assisted to receive SSI, after an initial rejection. SSI appeals are complex and require documentation, explanations, etc. Without support, the appeal would not have been successful.

She was taken to Housing Court by her landlord in April 2016 because there were arrears of more than $3,000. After numerous re-scheduling appointments, HRA paid the owed back rent. The next step was getting a letter from HRA stipulating this and a rental breakdown from the landlord. After several appointments and chasing of documents, a further rental lease was signed and renewed in July 2016. Her housing court case was closed.

This patient was also behind in utility payments. Once again, the H@R staff worked to connect her to Catholic Charities for assistance and after several meetings and arrangements, this need was also addressed.

When there are issues with her current landlord, case conferences including the H@R rep and housing case manager are used to address them periodically to ensure she remains housed. We recognize that cases like this require intensive staff time; we also recognize that the alternative may be more time in hospital with no safe discharge plan.

The team is also working to get her needed psychiatric and counseling support. She currently is considering job applications and preparing for job interviews.

Analysis/Outcome: The change in hospital utilization for this patient is very dramatic. From almost daily ED visits, In the year prior to placing her in housing she had 50 ED visits and 3 inpatient stays. In the year post housing (January 28th 2014) she had 2 ED visits both for legitimate reasons (pneumonia and lacerated finger). In 2016 she had 4 ED visits, 3 in 2017 and one overnight inpatient stay. The reasons included food poisoning and serious dizziness. We also note that in 2013 this patient also used Jacobi Hospital for additional ED visits and has not been back there at all. Thus, the Montefiore Housing@Risk Team’s work reduced overall Medicaid spending.

While there are multiple ‘case managers’ working with this patient, it is clear that she trusts only the H@R staff. Although there have been attempts to move that responsibility to others, the patient continues to use H@R resources in order to remain housed. When she is feeling uncomfortable about daily life issues, she comes to the H@R office to discuss them. Although moving her onto other providers is a goal, it is also important to acknowledge the need of patients to feel comfortable and for systems to acknowledge and accommodate people whose needs are such that long-term support is necessary to support stability and prevent unnecessary hospitalizations.

The Team’s work with her highlighted the need for improved access to psychiatric and counseling services. Meanwhile, her condition may deteriorate and need for more Team services to increase.

Patient 2 is 62-year-old patient who was homeless and needed a home in order to address her health conditions. She has ongoing depression/anxiety as well as severe COPD, diabetes, asthma and a history of substance use. She uses a walker and receives some home care services.

Housing Situation: This patient had a long history of housing instability, fragmented care and high hospital utilization. She was residing at a friend’s home in Westchester when she came to the attention of the H@R Team. The home was deemed a hostile environment that put her at risk for further hospitalizations. Although she uses a walker and oxygen, she was using a Metrocard to ride more than two hours by public transportation from Westchester to her long-time methadone program in Manhattan. That Metrocard program disqualified her from Medicaid ambulette services. For her income, she has SSI.

Intervention: The Team quickly assessed this patient and referred her to the BronxWorks MRT housing program. Because BronxWorks and the H@R Team have been working so well together, this process is efficient and effective. Transfer to the BronxWorks Health Home was also organized. BronxWorks located an appropriate unit in April. Meanwhile, in February, the patient was informed that she required a toe amputation. After the procedure she was placed in St. Barnabas Hospital for rehab. The Team worked with St. Barnabas Hospital and others to ensure she could stay there and then move directly to housing. In June, she moved into her new apartment, where she still lives. H@R arranged for the Montefiore Community Intervention Nurse Practitioner to work with her in her new community and coordinate local care for her. Also, the Team arranged for her belongings in Westchester to be moved into her new home and for food delivery. To support her going to various appointments, the Team successfully replaced the Metrocard service to a more appropriate Medicaid ambulette service.

Analysis/Outcome: True care coordination among agencies resulted in a homeless patient obtaining housing. These relationships were internal to Montefiore and external with St. Barnabas Hospital and BronxWorks.

Transfer to a Health Home associated with her housing aided coordination and shifted the work from the H@R Team.

Housing with wrap-around services to address behavioral health issues is necessary to prevent future incidents of homelessness and avoidable hospital services.

In the year prior to placing her in housing she had 8 ED visits and 9 lengthy inpatient stays. In the year post housing, she had 2 ED visits and 5 inpatient stays.

Conclusion: This population with a mixture of medical, behavioral and housing needs must be supported by integrated teams that address all these needs at the same time or in an appropriate sequence. These teams are often composed of staff working for several organizations—in these cases, housing and health is the key partnership. The patients who the Montefiore Housing @ Risk Team work with point to stable housing as a means to then address various medical and behavioral health needs. Although one major goal is increased independence, we have also learned that both the housing and health support require an investment of time and staff. As a result, the patient experience is more positive, the health situation improves and the cost decreases—meeting Triple Aim goals. These achievements are key motivators of these teams and help them support people well.

For further information, please contact Deirdre Sekulic at

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