Bridging healthcare and housing to end homelessness and improve health: Learnings from urban communities

Homelessness is associated with multiple health determinants: poverty, lack of social supports, hunger, unemployment, and suboptimal health care access. In the context of rising health care costs, nearly 2/3 of Medicaid recipients who are high cost due to frequent hospital admissions are homeless or unstably housed (Raven, MC et al, 2008). If effectively partnered with community-based organizations, the healthcare system can be an important point of intervention to improve medical care, social care and efficiency. This presentation will showcase the work of a network of communities addressing the health of community members experiencing homelessness by strengthening partnerships between health care, social service and housing providers. Specific emphasis will be on three urban communities' experiences in coordinating complex care with individuals whose health needs are not being met as evidenced by suboptimal use of health services. Strategies include eliciting clients' definitions of “quality health care,” the development of integrated care management teams, close linkages between primary and inpatient care, and the integration of healthcare and supportive housing. Client-level care models and systems integration will be explored. Focus will be on applying the Institute for Healthcare Improvement's Triple Aim: developing interventions that improve population health and patient experience of care while decreasing costs. Data measures and preliminary outcomes will be shared for chronic disease management, hospital utilization and associated costs, engagement in primary care, and housing placement. Replication and scale-up of successful interventions will be discussed.