Mixed Results in an Analysis of a Housing-and-Health Program in Boston

Though screening for housing instability has grown as a practice as patient care organizations have become more involved in value-based contracting, precisely how housing instability influences health status remains less clear. But an academic study of a primary care-based housing program in Boston for 1,139 patients with housing-related needs is showing that improved housing situations can reduce the number of primary care and outpatient care visits and lower the need for social work, behavioral health, psychiatric, and urgent care visits, while improving levels of mental health.

“Primary Care-Based Housing Program Reduced Outpatient Visits; Patients Reported Mental And Physician Health Benefits” was published in the February issue of Health Affairs. Its authors are MaryCatherine Arbour, Placidina Fico, Sidney Atwood, Na Yu, Lynn Hur, Maahika Srinivasan, and Richard Gitomer.

The authors begin by referencing some of the studies on housing insecurity and health that have been published, referencing one Boston safety-net hospital that found that 15 percent of the patients receiving care at that hospital had experienced homelessness or housing security. What’s more, studies have found that for every 1-percent increase in eviction rates in a county, mortality rates rose by 9.32 deaths per 100,000 people, with the strongest impacts observed in counties with high percentages of Black and female residents.

The article’s authors note that, “Although most health care–based housing interventions target homelessness,10 housing instability affects many patients and is also associated with poor health outcomes, less effective health care engagement, and higher health care costs. Less is known about health care–based programs that also support unstably housed patients to prevent homelessness and what role health systems can play,” they add.

The main focus of this article is on a program initiated in 2018 at Brigham Health in Boston, to screen for health-related social needs for all Medicaid ACO (accountable care organization) patients at the health system’s 15 primary care clinics, and the social care team created to address patients’ health-related social needs alongside clinical staff. “At the time,” they write, “Brigham Health data showed that 20 percent of patients screened positive for homelessness or unstable housing (that is, had multiple moves in twelve months or worried about losing housing within two months). This revealed an opportunity to intervene more upstream, aiming to support unhoused patients, prevent eviction, and improve chronic disease control and health equity, as patients were disproportionately Hispanic or Latino. Thus, beginning in late 2018, the social care team hired two housing advocates, who were community health workers specializing in supporting housing needs.”

The authors write that “A mixed-methods evaluation of Brigham Health’s housing program aimed to answer three questions: The first question was whether participation in the housing program was associated with differences in health care use or chronic disease control. The second question was what types of housing problems patients reported, what housing services were provided by the program, and what outcomes were seen after participation in the program. The third question was what patients’ experiences were with the program and what the perceived effects were on their health and well-being.”

The researchers’ findings? “Brigham Health’s housing program aimed to intervene more upstream to prevent homelessness and improve health care use and health outcomes. As expected, housing program participants were higher-risk patients at baseline18 compared with Brigham Health’s general primary care population: predominantly insured by Medicaid, female, non-White, and non-English-speaking, with more chronic conditions and higher emergency department and inpatient use. Our findings demonstrated a decrease in outpatient and primary care use among housing program participants compared with matched controls, but no difference in emergency department or inpatient use or chronic disease control. Despite housing advocates successfully navigating patients to the farthest endpoint within their locus of control (that is, subsidized housing waitlists), more than half of housing outcomes remained unknown. Patients reported health benefits, which they ascribed not only to obtaining new housing but also to advocates’ compassionate and respectful support. Some also expressed stronger connections to their health care institution.”

Based on their analysis, the researchers concluded that there was “mixed, mostly low-certainty evidence that housing interventions improved adult health outcomes.19 The review’s authors postulated that such interventions do not modify the root causes of health disparities that perpetuate unmet basic needs. Another possibility is that health benefits manifest on longer time scales. The Moving to Opportunity for Fair Housing Demonstration Program, which provided adults with housing vouchers, detected mental health benefits four to seven years later and physical health benefits ten to fifteen years later,” they note. The complexity, they write, is that, while hospital administrators seeking sustainable program funding report difficulties obtaining support amid constrained resources, even as the more compelling evidence of the impact of housing choice on health outcomes might take numerous years to fully manifest. Still, they note that the patients interviewed “effusively recounted the support and compassion they received from housing advocates while navigating intense housing stressors and the indignities of fractured systems—even among patients whose housing remained unchanged.”

The researchers admit that the future in this area remains murky, amid scarce funding for housing-related programs in healthcare, amid competing priorities and straitened resources. “This evaluation adds to a growing literature about health care–based housing interventions with mixed results,” they write. “It offers lessons for refining interventions to address needs among patients with imminent housing crises, to forge cross-sector partnerships necessary for innovating broader measures of success and rendering screening actionable, and to advocate for and create more affordable housing. Such interventions hold promise for redressing health inequities, for restoring dignity, and—if patient voice is centered—for rebuilding trust between historically marginalized populations and their health care institutions.”