Coordinating Housing and Health Care for Vulnerable Populations
Among affordable housing advocates and public health experts, consensus is growing on the need for more coordination between the housing and health sectors. Families experiencing homelessness require not only a stable roof over their heads but also access to wraparound services to meet basic needs. Inadequate medical and behavioral health care, for example, can increase susceptibility to homelessness; health challenges can affect job performance, leading to unemployment and an inability to afford health care. On November 19, 2020, the National League of Cities Virtual City Summit hosted “Homelessness and Health: Addressing Unmet Needs to Improve Outcomes,” moderated by David Fukuzawa, senior advisor to the president of the Kresge Foundation, in which panelists discussed best practices for adopting a holistic approach to address homelessness, tackling cross-sector collaboration and resource sharing, collecting homelessness data in real time, and valuing the voices of residents to foster systemic change.
Systems Integration for Coordinated Care
In her dual roles as director of the Sonoma County Department of Health Services and interim executive director of the Sonoma County Community Development Commission, Barbie Robinson leads a multidisciplinary team called ACCESS Sonoma County (Accessing Coordinated Care & Empowering Self-Sufficiency), which was formed in 2017 to identify ways to improve service coordination for residents vulnerable to homelessness. The ACCESS Sonoma County team ― composed of local officials, physicians, behavioral health and substance abuse counselors, probation officers, housing navigators, and public health experts ― has helped the county better understand the patterns and needs of high utilizers of services. Although they make up only 1 percent of Sonoma County’s population, each year from 2014 to 2018, high utilizers of multiple social services and programs accounted for an average of 28 percent of mental health expenses, 52 percent of nights spent in housing or shelters for the homeless, and 26 percent of prison time. Although high utilizers use services frequently, historically, this group has been difficult to identify and serve effectively because of a lack of information sharing across systems. Integrating data systems across various agencies, said Robinson, allows the county to redirect its resources to community clinics, which keep people out of the emergency room for routine care, and behavioral health and substance abuse services, which help people avoid prison. Data integration has also allowed stakeholders to create a coordinated care plan for each person served. The ability to “pull key data across those systems, to see in a holistic way, the needs of individuals, [and] what services they’re accessing in order to help them achieve their goals” has transformed how local government can best serve people in need, Robinson stated.
Dr. Bechara Choucair, senior vice president and chief health officer for Kaiser Foundation Health Plan, Inc. and Hospitals, discussed another program called Built for Zero that uses a data-driven approach to end homelessness. Kaiser Permanente partnered with Community Solutions, a nonprofit that aims to create a lasting end to homelessness, on Built for Zero, which uses real-time data rather than annual snapshots to identify people who are experiencing homelessness and tailor resources to their individual needs. Of the 84 communities participating in Built for Zero, 80 have achieved quality real-time data collection, 13 have ended chronic or veteran homelessness, and nearly 50 communities have measurably reduced homelessness rates. To increase the supply of affordable housing, Kaiser Permanente has also invested $200 million in the development of thousands of new or rehabilitated affordable housing units in the communities it serves.
Kaiser Permanente is also driving the policy change necessary to address the root causes of homelessness. Kaiser Permanente partnered with the de Beaumont Foundation in 2017 to create CityHealth, an effort that establishes criteria for assessing and rating a set of 9 evidenced-based policies, such as inclusionary zoning, earned sick leave, accessible prekindergarten, and Complete Streets programs, across 40 of the largest cities in the country. According to the CityHealth 2019 Policy Assessment, eight cities ― Dallas, San Antonio, San Francisco, Seattle, Boston, Chicago, Los Angeles, and New York ― achieved a gold medal rating based on the strength of their policies in each category.
The opioid epidemic is one public health issue requiring cross-sector collaboration and strong leadership from elected officials to build coalitions, said Steve Williams, mayor of Huntington, West Virginia. Initially, the city of Huntington lacked data on the community impacts of the opioid epidemic, but collaboration and resource sharing among public health departments, health centers, medical schools, hospitals, neighborhood groups, churches, and the local school system helped fill those gaps. In November 2014, Huntington established the Mayor’s Office of Drug Control Policy (MODCP) to foster a local and regional dialogue about opioid addiction. Small meetings of no more than five people at a time were critical to fully hearing all stakeholders’ views, Williams said. As a result, the MODCP has provided transitional housing, expanded treatment services, and made long-term outpatient services more widely available. Beyond the opioid epidemic, noted Williams, this “cooperative spirit” also established the institutional foundation necessary to help the city address homelessness and assist people to shelter in place amidst the COVID-19 pandemic.
Resident Engagement To Address Social Determinants of Health
According to Josie Williams, executive director of the Greensboro Housing Coalition, the most successful strategies are those that value the lived experiences of residents and consider them assets to fostering change. Williams discussed Collaborative Cottage Grove, a resident-led group of local government agencies, health officials, service providers, researchers, and housing advocates that was founded to address the housing and health disparities in the Cottage Grove neighborhood of Greensboro, North Carolina. As of 2018, the median annual income of Cottage Grove households was $12,000. Most of the community resides in rental units, many of which contained mold and other health hazards. With more than 40 percent of residents uninsured in 2018 and living in substandard housing that directly impacted their health, the community came together to develop solutions. Resident-led community action teams inform the priorities of the Collaborative Cottage Grove working group, which then identifies data to support those priorities and develops programs to address them.
In addition to opening a health clinic, the collaborative was instrumental in identifying a developer to renovate a 176-unit apartment complex whose residents endured poor living conditions contributing to health challenges, including asthma. In addition, stakeholders partnered with the Department of Environmental Quality to improve the conditions of a landfill that had negatively impacted neighborhood parks. A partnership with the city of Greensboro and a participatory budgeting process with residents resulted not only in remediated parks but also an increased capacity to improve the neighborhood’s quality of life. The story of Cottage Grove, emphasized Williams, “is more about the resilience of the community” and how partners aligned their vision with that of the residents to identify the priorities of the neighborhood.
Fostering Lasting ChangeAssisting individuals who are experiencing homelessness while also confronting health challenges, mental illness, substance use disorders, domestic violence, or a disability requires coordination among several stakeholders to truly address complex needs. As the panelists discussed, sharing data and resources across sectors is vital to identifying and implementing evidence-based solutions. High utilizers of services often cycle in and out of emergency rooms, jails, and shelters, and coordinated care plans based on information from a centralized system can better meet their needs. Involving residents in the decisionmaking process, along with establishing a mutual vision between officials and residents, builds trust among local communities and sustains improved quality of life. Working to end homelessness is an opportunity to improve stakeholder collaboration on a holistic approach to service delivery.