A Major Effort to Link Homeless Response and Health Care

The mantra “housing is health care” has been repeated by advocates for the homeless for decades. In recent years some have examined this concept from the other side, considering the potential for health-care systems to do more than treat and release the unhoused.

In 2017, a group of health systems formed the Healthcare Anchor Network, to harness their economic resources and community relationships to directly address social conditions that lead to poor health. The more than 65 organizations that have joined it to date employ over 2 million workers and have more than $150 billion in investment assets.

Two of the founding members of the network, Kaiser Permanente and CommonSpirit Health, are among the participants in a pilot project developed by the nonprofits Community Solutions and the Institute for Healthcare Improvement (IHI). The project is exploring how health-care systems can best help end chronic homelessness in their communities, with an intention to develop models than can be scaled nationally.

“Rather than counting housing outcomes, we wanted to see population level reductions in persons becoming homeless,” says Beth Sandor, co-director for Community Solutions. One way to do that is to leverage the power of large institutional players that have a disproportionate impact on their communities.

A Catalytic Partnership

In December 2004, IHI launched a 100,000 Lives Campaign, with a goal of preventing 100,000 needless deaths in hospitals by June 2006. More than 3,000 hospitals enrolled in the effort, which reduced deaths by 122,000 over its 18-month duration.

“We were really inspired by the impact of that work to drive change at scale across multiple health systems,” says Sandor. “We had been working with multiple communities around street homelessness, and we wanted to figure out what they were doing that was working in health care and apply it in our own space.”

IHI approached quality improvement from the perspective of systems change, an applied science that studies relationships between the parts of complex systems and how they work together (or don’t) to produce outcomes. Community Solutions modeled its 100,000 Homes initiative on the strategy IHI had used, setting (and exceeding) a target of housing 100,000 individuals in 86 communities.
In its next major effort, Built for Zero, Community Solutions used the same approach to collect real-time data about local homeless populations and to promote communication and collaboration toward shared goals among organizations providing services to the homeless.

Built for Zero launched in 2015; in 2020, Community Solutions won a global MacArthur Foundation competition for a single proposal most likely to lead to measurable progress toward a critical problem. The victory came with a $100 million grant.

The health care and homelessness pilot is built on strategies that both organizations have used to bring about quality improvements in systems where lack of information and non-coordinated effort made complex problems even harder to solve.

It’s not a matter of helping health systems develop “better relationships” with those involved in homeless response, according to Sandor, but using data and communication to discover how the full breadth of their resources can be aligned to accelerate population change.

One Part of the Picture

Niñon Lewis, vice president at IHI, has seen health systems move from a focus on individual care to thinking about their whole patient population, not just those who arrive for treatment.

That gave way to a realization that health care is only one determinant of health, she says. “In the breakdown of what contributes to an individual's health and well-being, health care is actually a pretty small part of it.”

The Affordable Care Act ushered in a new payment environment, helping the growth of accountable care organizations rewarded for outcomes, not just service delivery, encouraging prevention and coordination across a continuum of care. New payment models, along with better rewards for better results, created incentives for those involved in accountable care to consider how they might address social determinants of health.

For years, IHI had shared methods to improve the quality of health care, and to help Community Solutions enhance homeless services. “About four or five years ago we started to say that maybe our partnership doesn't have to just be about quality improvement methods,” says Lewis. “It could be about what would it take for us to learn together what health care's role could be in reducing or ending chronic homelessness.”

Six health systems are participating in the three-year pilot. In addition to Kaiser and CommonSpirit, they include Providence, Trinity Health, UC Davis Health and Sutter Health. There are five pilot sites: Bakersfield/Kern County, Calif; Sacramento County, Calif; Anchorage, Alaska, and Chattanooga, Tenn. All are part of the Built for Zero network.

The project will base its work on a theory of change incorporating five “pillar” areas of strategy that, working together, could enable health systems to play a significant role in reducing homelessness. These range from preventing inflow into the homeless population to targeted use of financial resources. (See diagram for additional details.)

In addition to social and humanitarian benefits to communities, there’s a business case for this work, Lewis says. “You might be discharging someone into the street, and you know they’re going to come right back into the emergency department if you don’t figure out what to do.”

Moving the Needle

Kaiser Permanente, the nation’s largest managed care organization with 12.5 million members, is a health-care partner in three of the pilot sites: Sacramento, Bakersfield and Anchorage.

“We have been thinking for a long time about the critical role that health systems can play in helping communities reduce and end homelessness,” says Vanessa Davis, national program lead for housing for health at Kaiser. “The mortality rates of people experiencing chronic homelessness are three or four times higher, and without a stable place to live, it’s nearly impossible to maintain improvements achieved in a medical setting.”

Partnering with the National Institute for Medical Respite Care, Kaiser has invested in housing, including short-term accommodations for unhoused patients who no longer need hospital care but have not recovered sufficiently to be released to a shelter. It gave a grant of $25 million to Project Homekey, working with the state of California, to provide public entities with funding to convert hotels, motels and other unused properties into interim and permanent supportive housing.

Collaborating with the National Center for Medical-Legal Partnership, Kaiser has invested in giving patients access to assistance with legal issues that threaten their housing stability.

“We can demonstrate that we can move the needle, but we know it’s going to take all of us,” says Davis. “It takes health systems, policymakers, private-sector businesses and other leaders across sectors to commit to making change at the system level.”

“Everyone wants to solve this problem, but once you really get into it, it is complex and layered,” says Trish Rodriguez, senior vice president and area manager for Kaiser Permanente. “You have to start at that fundamental level of collaboration.”

Over the course of her career, Rodriguez has heard many opinions about what the “real” problem of homelessness might be. “There have been a lot of anecdotes, people making things up, saying if we do just one thing it will solve the problem.”

People approach the problem of homelessness with good intentions, she says, data systems are essential to building common understanding of the best ways to work together. “When you’re dealing with a problem this vast, you have to prioritize.”

Speaking Different Languages

CommonSpirit Health, another partner in the pilot, is one of the nation’s largest nonprofit health systems, serving 20 million patients in 21 states. It is a partner in IHI/Community Solutions pilots in California and Tennessee.

The pilot aims to break down fragmentation and spark collaboration between homeless service and health-care providers, says Ashley Brand, system director for community health integration and housing for CommonSpirit.

“Often, we speak very different languages when we’re talking about the same population,” says Brand. “We wanted to bring in our care coordinators to understand the nuances of homeless management information systems [HMIS], and what it might look like for the HMIS and EHR [Electronic Health Records] to actually communicate.”

It hasn’t been a routine practice to ask patients questions about matters such as rent problems, food security or access to housing benefits, but Brand sees the development of risk-factor screens as a long-term goal.

CommonSpirit is also establishing a medical-legal partnership in Sacramento which could help patients deal with landlords who neglect housing issues, such as mold, that can contribute to health problems, as well as lease or eviction problems.

The pilot sites CommonSpirit chose were designed to help it learn how best practices might differ in rural, urban and metropolitan communities, says Brand. “Each region was at a different place in terms of the engagement between the health systems and the local homeless continuum of care. We wanted diverse environments so that we could replicate this type of model across our entire footprint.”

Early Lessons

The pandemic delayed the March 2020 launch of the health care and homelessness project. Initially intended to be a two-year effort, it was extended to three.

The challenges of the first year included figuring out a way for homeless response systems and health-care staff in the pilot communities to speak the same language, says Beth Sandor. Data sharing was another issue: What can people in the homeless response learn about people in the health-care system, and vice versa, while adhering to privacy laws?

“You need to understand the range of data we would need to do everything from case conferencing or care coordination to seeing if we are making reductions in the overall population,” says Sandor. “But solving these problems sometimes comes down to these very wonky details.”

For example, the definitions of homelessness are not the same in health and homeless response data systems. This complicates communication between data systems as well as people. Data collection and management, as well as coordination between entities, depends on people. Staffing is another issue that needs to be explored.

“What’s the infrastructure you need for collaboration?” asks IHI’s Lewis. It might make sense to have social workers or homeless case managers sit within health systems, even though they are part of a homeless response system.

In some cases, a health system may be involved in community benefit programs that hospital staff know nothing about. Case conferencing, a long-time practice in the homeless response system to coordinate entry into housing, could benefit from the unique perspective of physicians and nurses.

Even as the pilot works through such puzzles, incremental change has begun in pilot communities. Health managers are seeing more referrals from care systems to homeless case managers. Persons who show up for treatment who are not in homeless management information systems, but should be, are entered in them.

The existence of Built for Zero programs in the participating locations means that a culture of reliance on data and coordinated effort already exists, at least within the homeless response sector. Now it’s a matter of bringing health care into the fold.

COVID-19 and Political Will

COVID-19 may have delayed the start of the work Community Solutions and IHI had planned, but it’s possible that it added to the appetite for it. The pandemic exacerbated inequalities that had always existed in communities, but for some this was a new idea, says Lewis, one that prompted them to take a new look at the interplay of health and social conditions.

In addition, health systems sped up staffing faster than anyone thought was possible, in days versus months. That shifted perceptions about the resilience of health systems and their ability to implement new ways of working.
Even before the pandemic, Sandor says, political will was gathering around a need for change within health-care systems. The original intention of the pilot was to tap into this and bring together public health, health systems and homeless response.

For a time, COVID-19 took public health out of this equation, but that’s changing. “There’s more capacity and more ability to think about things outside of emergency response,” she says. “Now is the right time to bring public health to the table.”

Some health systems are still working on the leap from individually coordinated and delivered care to thinking about a patient population, says Lewis. Others have moved beyond the physical needs of patients, to the social, to health of their communities.

“That’s a progression of maturation on the journey to what we would call population health,” she says. “Those that are on this edge are not just saying, ‘We need to work on housing,’ they’re actually doing it.”