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YYY: The marriage of housing and health care: a fruitful match

The marriage of housing and health care: a fruitful match

 Street Roots (USA) 14 June 2019

Many sick homeless people in the United States seek care, but they often wait until they are so acute in their needs they need go to hospital emergency departments. Heather Lyons analyses what can be done to address the issue. (1174 words) - By Heather Lyons

Last week, in a cab from the airport en route to the Health Care for the Homeless Conference in San Francisco, the driver asked me what I did for a living. I always pause when I get that question from a stranger on the road. Experience tells me that I will get one of three responses if I answer truthfully. Usually it's either a) criticism for supporting socialism (one driver in Alaska blamed me for helping, "the U.S. to become a 'nanny country'") b) useless advice on what should really be done for the homeless ("They should have them on exercise bikes and connected to electricity to power buildings." That from a seatmate on a flight to Denver), or, c) something supportive, and usually benign ("That's nice, you must really enjoy doing that."). A colleague of mine lies when she's asked her profession. She tells people she's a party planner. She's actually created a whole new persona just for such situations.

This last time was different, though. He seemed to understand the challenges that disabled homeless people face. Without much explanation of what I did, his first reaction was that the government should take care of people more because families aren't around to do it the same way they did in his parents' generation. He also had direct experience. He spends a lot of time driving people to and from hospitals. He said that these people are still very sick, can barely move, and he is shocked at where he drops some of them off.

Many sick homeless people seek care, but they often wait until they are acute in their needs, and they go to hospital emergency departments. Many will also use the emergency departments as their primary care providers. There are two main reasons for this. One, most hospitals cannot turn them away, even if they don't have health insurance (and the vast majority do not), and two, it becomes a habit. If a person learns that care comes by going to a certain place, even if it is the emergency department, then that is the place to go.

There are also big problems with using emergency departments as "medical homes." To start with, it's not a place to receive ongoing care. Emergency department's are not set up to provide that level of care for people. They are set up for crisis interventions. And it's extremely expensive, especially if people are admitted to inpatient care in the hospital. Even if people have insurance (Medicaid or otherwise), the insurance costs go through the roof if they are using hospitals instead of community-based health centers for their healthcare needs.

An initiative in California, called the Frequent Users of Health Services Initiative, or FUHSI, set out to document this under an effort to provide health care for identified frequent users in six communities. The data was overwhelming.  Out of 1,081 participants studied, on average, FUHSI participants experienced:

         8.9 emergency room visits each annually, with average annual charges of $13,000 per patient

         5.8 inpatient days each, with average annual charges of $45,000 per patient

Additionally, people were definitely experiencing many physical health and social problems:

         65 percent had chronic illness (diabetes, cardiovascular disease, chronic pain, cirrhosis and other liver disease, asthma and other respiratory disease, seizures, hepatitis C, and HIV)

         53 percent had substance use issues (alcohol, methamphetamines, crack/cocaine, heroin, prescription drugs)

         45 percent were homeless, living on the streets

         32 percent had a mental illness

         36 percent had 3 or more of these presenting conditions


Fortunately, these folks were able to receive an intervention of services, and some of them received housing, too. I'll get back to that in a second.

So, why don't all homeless people use community-based health centers? Again, two big reasons. One, many do not have health insurance. Not all clinics require insurance, but in order to make ends meet, they must limit the number of uninsured patients they can see. Many still see more uninsured patients than they should, but it's hard on their budgets. That will change in 2014 with the full implementation of Health Care Reform and everyone under 133 percent of poverty level will have health insurance.

Two, even if they have insurance that does not mean they will access health care regularly, in a community based setting. In fact, data show that besides healthcare itself, nothing improves healthcare outcomes for homeless people as much as the addition of stable housing. Back to the FUHSI study. Not all programs involved in FUHSI were able to provide housing, but those that did showed some amazing results:

Homeless frequent users receiving services and connected to permanent housing

         Reduced average ED visits 34 percent

         Reduced average inpatient days 27 percent

         Reduced average inpatient charges 27 percent


Homeless frequent users receiving services but not connected to permanent housing

         Reduced average emergency room visits 12 percent

         Increased average inpatient days 26 percent

         Increased average inpatient charges 49 percent

So, those individuals who were not housed, while they decreased their emergency department stays and costs, they actually increased their inpatient days and charges. Because they didn't have a "health care home," they were not able to receive the kind of care that prevented them from continuing to use hospitals for their medical needs.

The answers are, frankly, obvious. Why then, is it so hard to make the answers a reality? Why is every effort to combine services and housing a herculean effort by almost any standard? And, why do I hear from service providers complaints about how there isn't any housing, and complaints from housing providers that there aren't any services?

Because the systemic changes that need to occur, to make it easier for people to create and operate supportive housing have not happened. Housing is complicated, services are complicated, bringing the two together in a sustained effort to end the homelessness of the most vulnerable people on the streets is very hard, which makes it easy to give up and slide back into emergency and temporary response. 30 years of that type of response tells us it doesn't work.

We can sit around and complain about things that we can't control, like the economy, like the federal disinvestment in affordable housing, like the erosion of the safety net. Or, we can dig in, work with smart people who know how to bring these complicated systems together, and at least make an effort to rectify the dysfunction within local systems in our communities to help make it easier for providers to create and sustain supportive housing.

Let's honor the concerns of the cab driver I had in San Francisco, and let's try to get government to do more to take care of it. Not by raising taxes (though, I'm personally not against raising revenue when the environment calls for it), but by taking a good look at what is working and what isn't for people who are on the streets, are frequent users of expensive systems, and are very vulnerable.

Bio: Heather Lyons lives in Portland, and works for the Corporation for Supportive Housing's National

Consulting and Training Team to promote systems and policy change to create supportive housing to end

homelessness. Prior to this position, Ms. Lyons led the City of Portland's efforts to end homelessness, with

numerous partners, under the policy framework of Home Again: A 10-Year Plan to End Homelessness.


Please credit article as follows:

Originally published by Street Roots. ©

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