Housing—and the lack of access to it—has long been recognized as a critical social determinant of health. The outstanding question for health care leaders is not whether health systems have a role to play but how they can make the most transformative impact in addressing homelessness.
In December 2020, nonprofits Community Solutions and the Institute for Healthcare Improvement launched the Healthcare and Homelessness Pilot, a three-year project with financial support from Kaiser Permanente, Providence Health, and Common Spirit. The pilot aimed to identify effective models for cross-sector collaboration between health and homeless response systems and sought to understand: the key partnerships and practices needed to facilitate optimal health and housing outcomes for unhoused individuals; and how these partnerships could operate at a systems level to ensure a community can measurably and equitably reduce homelessness.
Several major health systems—including Kaiser Permanente, Providence Health, CommonSpirit Health, UC Davis Health, and Sutter Health—participated in the pilot, which brought together leaders from these health systems and local homeless response in five communities: Bakersfield and Sacramento, California; Anchorage, Alaska; Washington County, Oregon; and Chattanooga, Tennessee.
The collaboration between systems builds on an increasing awareness by health providers that they have a so-called “anchor mission” to better support and invest in the health of their communities. Anchor missions are set by institutions with a commitment to deploy long-term economic power, connections, and other resources to improve welfare within the surrounding community.
Over the course of the initiative, communities designed cross-sector projects aimed at reducing and ending homelessness, promoting racial equity, lowering health care costs, and improving overall health outcomes. Through this pilot, a theory of change about health care’s role in ending homelessness was tested and refined. This theory includes three major pillar areas: building bi-directional awareness and commitment; establishing structures for cross-sector partnerships; and participating in a holistic system of care.
Each site worked with a multidisciplinary coaching team, including an improvement coach from the housing and homelessness sector and faculty with expertise in change management and population-focused transformation in health systems. The initiative fostered a learning community among sites committed to building relationships, actively testing changes, sharing what does and does not work, adapting ideas, and tracking progress.
This article represents a number of lessons that we learned while supporting this pilot. In particular, it details four key roles that, based on our experience over the past three years, we believe health systems can play to help communities tackle homelessness: identifying patients in need of housing services; preventing discharge into homelessness; data sharing; and improving coordination of health and housing services with cross-sector case conferencing.
Identifying Patients In Need Of Housing Services
Health care systems can play a vital role in identifying and supporting individuals experiencing homelessness or housing crises earlier. Participating pilot sites demonstrate that implementing social determinants of health (SDOH) screenings in health care settings can improve early identification and support, reduce inflow into homelessness, and increase housing placements.
A Critical Component
To address homelessness, communities must understand who is experiencing homelessness at any given time, how that number is changing month over month, and other population-level dynamics, such as inflow and outflow from homelessness. Screenings with health systems can help ensure that these data are comprehensive and that all unhoused neighbors are accounted for. Hospitals have been able to alert the homeless response system of patients that are experiencing homelessness who were previously unknown to the homeless response system. When a client is screened and referred to the homeless response system, the constellation of service providers within the Continuum of Care (CoC) Program can connect this person with services and support the process of them accessing and moving into safe, affordable, and stable housing.
Pilot sites have observed that for SDOH to promote these outcomes, they must be conducted in an empathic, trauma-informed, and culturally responsive manner. SDOH screenings should also be integrated into a system-level workflow designed to address social needs and connect patients with community-based services.
Resources
Several SDOH screening tools are available for health care systems to adapt based on their clinical setting and patient population, including the PRAPARE Screening Tool, the Centers for Medicare and Medicaid Services’ Accountable Health Communities Health-Related Social Needs Screening Tool, and the American Academy of Family Physicians’ Social Needs Screening Tool. PRAPARE offers a comprehensive toolkit to guide training and implementation, while complementary resources such as the CLEAR toolkit and the American Hospital Association’s tool for care teams assist health care providers in conducting screenings. The information collected through SDOH screenings is vital to effectively coordinate across systems to inform treatment plans and better meet the needs of individuals experiencing homelessness through connection to appropriate resources and care.
Despite the availability of these tools, health care systems encounter challenges in implementing universal SDOH screening due to barriers such as limited leadership buy-in, staffing constraints, lack of centralized data systems, and feelings of inefficacy in addressing complex social needs. Overcoming these challenges and making SDOH screening a standard practice requires enterprise-level initiatives with visible leadership commitment, standardized protocols, robust and ongoing staff training, electronic health record integration, quality improvement efforts, community partnerships, and demonstration of outcomes due to the collection this information.
The ultimate goal is to seamlessly integrate screenings into existing care workflows, creating a culture in which routine SDOH screening and addressing social needs become integral to health care delivery.
Preventing Discharge Into Homelessness
Hospital discharge is an important juncture in a patient’s care journey that presents opportunities to address their health and social needs. Health systems can prevent homelessness and increase housing placements through standardized discharge planning and housing referral processes for patients experiencing homelessness or housing instability. Effective discharge planning diverts patients from homelessness, directing them to supportive services or coordinated entry into the homeless response system, and can contribute to broader efforts to address population-level health inequities.
A Dedicated Liaison
Often, when a hospitalized individual is identified as experiencing homelessness, medical social workers may still struggle to help. Systemic obstacles can limit these social workers’ ability to consistently connect individuals to longer-term housing navigation services. For this reason, Kaiser Permanente, a health partner engaged in the pilot efforts in Sacramento known as Healthcare x Homelessness, secured funding for a dedicated liaison position within the hospital to work across systems, connecting to the CoC and other health systems.
The purpose of this liaison position is to coordinate post-discharge care and provide navigation support to appropriate housing resources, fostering joint accountability and improving coordination across systems to improve outcomes for people experiencing homelessness. Although this position is still new, early indicators show that having a person dedicated to the coordination between systems and referral processes has resulted in increased connections to primary care providers and decreased hospital utilization rates.
Unfortunately, despite coordination efforts, homeless response systems often do not have suitable settings for individuals with complex medical needs, leaving few discharge options for unhoused patients. However, some pilot sites have been able to turn to medical respite programs that provide short-term, residential care for patients experiencing homelessness who no longer require hospitalization, but need a safe, supportive environment to recover from illness or injury.
In Anchorage, Alaska, Monique Crespo was living at Centennial Campground when she endured a serious fall and head injury. Monique stayed in the hospital for more than a week, after which she was referred to the medical respite program at the Brother Francis Shelter in Anchorage. From there, she was connected to the Complex Care Shelter, where she could stay for a prolonged period of time to recover and receive care. Through community coordination and tireless work with her case manager, Monique moved into her own apartment in June 2023. Monique’s experience shows how effective referrals and follow-up care in transitional housing can ensure discharge to appropriate settings, and ultimately facilitate permanent housing solutions.
Resources
Pilot sites have observed that dedicated liaisons working across systems significantly improve safe and coordinated discharge arrangements for patients experiencing housing instability or homelessness. Community Solutions and the Institute for Healthcare Improvement developed a Liaison Toolkit for communities that are interested in learning more about bringing on liaisons to strengthen engagement and improve outcomes across health care and homeless response systems.
In addition to our observations during the pilot, several studies have found medical respite programs can reduce inpatient hospitalization and readmission rates, reduce gaps in services, and improve health outcomes. An increasing number of states and managed care organizations are offering payment for medical respite care through Medicaid 1115 waivers. The National Institute for Medical Respite Care provides a comprehensive toolkit to help communities plan, develop, and sustain medical respite care programs.
Data Sharing Between Homeless Response And Health Systems
Cross-sector data sharing is a key component of impactful collaborations between health and homeless response systems. Throughout the pilot, participating sites have been establishing data-sharing agreements and practices between local health and homeless response systems.
An Opportunity
In Sacramento, Kaiser Permanente, CommonSpirit Health, and UC Davis Health created data-sharing agreements with Sacramento Steps Forward, the lead agency coordinating housing services and homeless response funding. These agreements provide systems the opportunity to examine aggregate data and better understand population-level trends in health needs and outcomes of patients experiencing homelessness. The process also highlights gaps in the data landscape that system leaders can then aim to close in future agreements and partnerships.
Meanwhile, the data-sharing agreements have begun to allow the Sacramento health systems to receive comprehensive and person-specific data on those persons experiencing homelessness and match against hospital medical records. This enables the health systems and the homeless response system to better coordinate care. And over the long term such coordination should help improve health and housing outcomes and experiences for vulnerable individuals who currently rely upon emergency services to address their unmet social health needs.
In Washington County, Kaiser Permanente, Providence Health, and the county established unidirectional data-sharing agreements between the CoC and each health system, which enable health systems to receive lists of unhoused people from CoC’s Homeless Management Information Systems. Health Share of Oregon, a coordinated care organization serving Oregon Health Plan (Medicaid) members in multiple counties, recently joined the agreement and is managing the data flow between systems.
These agreements enable cross-sector case conferencing (as described below) to better understand the population of patients known to both the homeless response and health systems—and achieve successful housing placements and health outcomes for that population.
Participating systems have also engaged CareOregon, the entity responsible for managing behavioral health benefits for Medicaid members, to join the data-sharing agreement in Washington County, along with other health systems.
Resources
Community partners who executed these data-sharing agreements at participating sites emphasize that the process takes time. This starts with incremental steps such as aggregate data sharing, staying adaptable, prioritizing relationship building, learning from other communities and health systems, and ensuring data requests align with meaningful outcomes. To assist in this complex process, Community Solutions has developed a data-sharing toolkit highlighting the spectrum of possible data-sharing arrangements between health and homeless response systems. The California Healthcare Foundation has also produced a roadmap for implementing data sharing to better serve underserved populations.
Improving Coordination For Housing And Health Services With Cross-Sector Case Conferencing
Health systems can significantly contribute to ending homelessness in their community by participating in cross-sector case conferencing, a routine meeting for finding housing solutions for people experiencing homelessness.
A Path To Actionable Solutions
These meetings allow health care partners, such as physicians and hospital social workers to apply their expertise and perspectives to coordinated community efforts to end homelessness. They can also lead to actionable solutions, such as targeting resources toward high users of health care systems who are actively experiencing homelessness.
In Washington County, regular medical case conferencing meetings, supported by data-sharing agreements, bring together staff from Kaiser Permanente, Providence Health, Health Share, and the CoC to coordinate care for homeless individuals with unmet medical needs. Health care coordinators and housing case managers assess client needs in both the homeless and health care systems, develop plans across sectors, and bring together resources to close gaps in care.
These meetings strengthen relationships between the health and housing teams, expedite resolution of complex situations, and ultimately, lead to new ways of working across systems. These new approaches include coordinating care, joint problem-solving and accountability, successful discharge, and the identification of individuals experiencing homelessness.
Resources
Effective cross-sector case conferencing focuses on the patient above all else. This includes a cross-sector team representing all relevant agencies and fostering collaborative problem-solving. And it is increasingly being used to serve complex and underserved populations, particularly as communities move toward value-based payment and integrate SDOH in care delivery. Various models have shown different ways coordination can improve care and reduce use for individuals with complex needs. The Behavioral Health Network of Greater St. Louis, for example, pursued an approach that emphasized a cross-sector network of care, considered key medical and social factors, and aimed to achieve cost savings.
Community Solutions provides a case conferencing tool bank that can be applied to a cross-sector context.
Next Steps
The Healthcare and Homelessness Pilot ended in December 2023; however, the cross-sector collaborative work in all five communities has continued beyond the pilot with on-going commitment from health systems, CoCs, and Community Solutions. In this next phase of work, the focus has been on sustaining partnerships between health care and homelessness response systems in each community, expanding system changes such as data sharing and cross-sector case conferencing, and scaling the work across a broader footprint.
We are continuing to refine our model and document learnings for how health systems can make meaningful, measurable, and transformative contributions to ending homelessness.
Considering the inextricable links among homelessness, poor health outcomes, and increased health care use, it’s time to empower health care leaders to embrace cross-sector collaboration, data sharing for care coordination, and collective action toward ending homelessness in every community. Health systems have the power to drive systematic and sustained improvements in the care for people experiencing homelessness. This system-level work is imperative for healthier and more equitable communities.
