How Boston, Seattle, and Austin PHAs are Addressing Resident Health

Several of the nation's public housing agencies (PHAs) have taken steps to address the chronic health issues of their residents. At the same time, an increasing number of healthcare providers are acknowledging the impact of housing on physical and mental health. As a result, PHAs and healthcare providers have been forming partnerships to address the health and housing needs of vulnerable residents. Some of these partnerships address specific health concerns; for example, in 2011, the Boston Public Health Commission (BPHC) partnered with the Boston Housing Authority (BHA) to form Healthy Start in Housing to provide stable housing and support services for young women with high-risk pregnancies. Similarly, the Seattle Housing Authority's (SHA's) Behavioral Health Outreach Program (BHOP), founded in 2019, serves public housing residents with behavioral health concerns through contracts with two local providers. Other efforts have adopted a broader approach to health care for public housing residents. The Housing Authority of the City of Austin's (HACA's) recent partnership with a federally qualified health center (FQHC) led to an onsite health clinic that provides various health and wellness services for public housing residents and the community at large. BHA, SHA, and HACA were initially interviewed by staff from the U.S. Department of Housing and Urban Development's Office of Policy Development and Research, Veronica Garrison and Jacquie Bachand, in 2020. This article is based on those interviews and follow-up conversations with BHA, SHA, and HACA staff in 2024.

Boston's Healthy Start in Housing

In response to a 2009 study on infant mortality, BPHC and the city of Boston, under the mayor's leadership, began working with BHA to promote housing stability for low-income women with high-risk pregnancies, many of whom were living on the streets. In November 2011, BHA entered into a memorandum of agreement with BPHC to launch the Healthy Start in Housing program for women with high-risk pregnancies as well as families with young mothers or babies with high-risk medical issues. BPHC identifies and screens eligible families for Healthy Start in Housing. If BHA approves the tenants and they meet the standard eligibility requirements for public housing residents, these families can move into any available BHA public housing unit. Although the agreement allows up to 75 households to participate in the program, BHA does not reserve or prioritize any units for program participants and accepts all households eligible for public housing according to its Admissions and Continued Occupancy Policy on a first-come, first-served basis. BHA receives no additional funding for this program.

BPHC nurses and social workers provide home health care to program participants. In addition to offering physical and emotional support, staff work with residents on their independent service plans, in which they lay out specific goals. These goals can be health or other personal goals, such as setting a budget or purchasing a car.

As of 2017, residents who are in stable condition after 18 months can graduate from the program if BPHC and BHA staff determine that they have met the goals of their independent service plan. Families who graduate remain in their public housing unit but release one of the 75 available Healthy Start in Housing slots for a new household. As of 2021, 53 of the 146 program participants had graduated from the program. The program has undergone other changes in recent years, such as allowing fathers with custody of their children to participate and removing the city residency requirement. As John Kane, BHA's coordinator of grants and strategic partnerships, explained, "The two public agencies working together without the benefit of grant funds are committing their vital resources in a stable long-term partnership to address an important community health and housing need."

Seattle's Behavioral Health Outreach Program 

In late 2017, the mayor of Seattle, in coordination with local stakeholders, made addressing behavioral health a major goal of the city's homelessness prevention strategies. People with behavioral health issues are more likely to experience housing instability and cannot always access needed care. During this time, SHA public housing tenants and staff were experiencing issues with residents causing disruptions in the buildings. In 2019, SHA undertook a comprehensive behavioral health needs assessment of residents and found that residents' behavioral problems were rooted in various conditions, including mental health and substance use disorders. That same year, the agency entered into a data-sharing agreement with the King County Behavioral Health and Recovery Division and discovered that nearly one-quarter of public housing residents were already enrolled in Medicaid-funded behavioral health services. These findings led to discussions with King County about developing a behavioral health program for SHA residents, originally called Housing Outreach Partners. The county initially planned to expend nearly $2 million for the program; however, a significant drop in sales tax revenue during the COVID-19 pandemic forced the county to withdraw support. Amid mounting concerns about a post-COVID tsunami of behavioral health crises, SHA funded and launched the program, rebranded as the Behavioral Health Outreach Program (BHOP), the following year.

BHOP is designed to help those who exhibit outwardly disruptive behavior and are underserved by community-based behavioral health resources but do not need more intensive interventions such as involuntary services. SHA contracts with two nonprofit service providers, Sound and Southeast Youth and Family Services, to serve residents exhibiting behavioral health issues. The staff work with residents individually and as a group on managing stress, responding to crises, and dealing with grief. A key component of the program is building relationships with residents. Andy Chan, a strategic advisor at SHA, argues that building trust and collaborating with residents is far more effective than merely encouraging or requiring them to seek help from a professional in an office, even if it takes longer. This approach involves "working with the person to recognize where improvements can be made, where there are safety problems, and things like that," he said. Chan cited hoarding disorder as an example of the importance of building relationships with residents and working with them on a personal level. A resident with dementia who forgets to take out the garbage might be misdiagnosed as a hoarder.

Chan explained that BHOP staff have seen the benefits of this approach firsthand, explaining how, for example, a resident who suddenly began to scream at others and associate with an alleged drug dealer was restabilized after staff paid her several home visits and reconnected her with healthcare providers. Nearly 80 percent of residents referred to BHOP accepted services, which, according to the 2023 program evaluation, "points to the success of providers' trust and relationship-building efforts." As of 2024, BHOP serves approximately 100 people, including some housing choice voucher recipients.

Austin Federally Qualified Health Center Partnerships

Recognizing that its health and wellness services for nonelderly residents were limited, HACA also conducted a community needs assessment at four of its properties in 2019. The surveys, which had a 70 percent response rate, revealed that many residents were not being proactive about their health. Relatively few residents were seeing primary care physicians regularly or getting preventative screenings or exams. As in Seattle, HACA staff attributed this apathy largely to a lack of trust and solid relationships with the medical community. At the same time, however, the needs assessment found that public housing residents overwhelmingly favored more healthcare services in their public housing community. According to the surveys, 90 percent of respondents were interested in direct medical care, 85 percent wanted access to community health workers, and 82 percent requested that testing and health products be made available. These results helped guide HACA's internal programming as well as its partnerships with FQHCs, which are federally funded health centers that serve medically underserved areas and residents.

In 2020, HACA partnered with CommUnityCare, an Austin-based FQHC that the assessment found was already the provider of choice for nearly half of residents. CommUnityCare opened a temporary flu clinic onsite. Three years later, CommUnityCare opened the first health clinic on a HACA public housing site.  The Chalmers Courts Health Clinic is a 5,000-square-foot health center serving residents of HACA's Chalmers Courts development as well as the broader community. The clinic offers family primary care, behavioral care, dental care, lab services, and care coordination and management. In exchange for space at Chalmers Courts, CommUnityCare agreed to reserve 15 percent of weekly medical appointments and 10 percent of weekly dental appointments at this clinic for HACA residents.

According to Borami Lee, HACA's program manager of Health and Wellness, increasing in-person programming and services since the height of the pandemic has helped residents build trusting relationships with HACA's Community Health Workers (CHWs). "CHWs educate the community on patient activation to increase health related self-advocacy and work as a liaison to link residents to healthcare professionals," Lee explained. She believes that HACA's health-related efforts have significantly increased the number of residents who schedule routine health visits. In fact, since the health center opened at Chalmers Courts, clinic usage by HACA residents has increased by roughly 350 percent. Since 2022, HACA has also been working with CommUnityCare and People's Community Clinic, another FQHC, on an initiative to increase patient activation measures to gauge residents' ability to manage their own health conditions.

Successes and Limitations

Staff from all three PHAs expressed optimism that these housing agencies can continue to support residents' healthcare needs. However, they noted that funding limitations and capacity constraints present barriers to significantly expanding these programs. Without social workers or nurses on staff and with limited revenue sources outside of normal operating funds, PHAs often have to rely on innovative partnerships with service providers to offer these types of programs. Some PHA staff alluded to the possibility of future funding increases from healthcare providers or the federal or state government. In the meantime, PHAs can use their own tools, such as adding the graduation component, to maximize the total number of families receiving care.

Although Healthy Start in Housing, BHOP, and Austin's FQHC partnership differ in size and scope, their foundations have some common elements. Each program was formed in response to an indepth study of PHA residents' needs. HACA and SHA relied on significant resident engagement when designing these programs. Further, SHA's and BHA's programs had roots in mayoral initiatives, suggesting strong support from local governments. These efforts suggest that, through resident engagement, health services utilization data, and partnership building, PHAs can increase health coverage for their residents.