The program transitions chronically homeless patients from the Emergency Room into permanent supportive housing. Their partner, the Center For Housing & Health, has developed a network of 27 supportive housing providers representing ~4,000 scattered site one bedroom apartments dispersed throughout Chicago. The project has housed 59 patients to date, and has found very high mortality (34%) and high rates of uncontrolled chronic disease. Housing is health - it is as a dangerous health condition.
When the program started there were no obvious, solid business reasons for a hospital to pay for housing. However, as a state institution that serves the indigent of the state, the University of Illinois Hospital & Health Sciences System (UI Health) began to recognize their obligation to focus on the health of the communities that we serve, not just individual patient care.
They have discovered that homelessness carries significant health risks, with a 34% mortality rate in their first cohort of 26 patients, and high rates of uncontrolled disease, serious mental illness and substance use. Once housed, they saw healthcare utilization and cost decrease significantly (45% overall).
UI Health is actively encouraging other hospitals to view this as an intractable issue that can only be solved through collective impact, and "all-in" approach where competitors and stakeholders cooperate to address a serious public health concern. To that end, UI Health is one of the founding members of the cross-sector partnership, the Flexible Housing Pool, a common funding mechanism that aggregates fragmented funding sources into a unified stream. Working with government agencies, and supportive housing providers, UI Health have garnered $8m with a goal of $12m from the city, county, insurance companies, other hospitals, and philanthropic organizations. UI Health hope to have financial contributions from the jails and prisons, since they know that homelessness is a key driver of recidivism.
The multiplier effect of the FHP is that it will create increased housing capacity - once fully funded, there will be approximately 750 more supportive housing units available throughout the city.
Another innovation is the use of Natural Language Processing (NLP) to identify homelessness in an electronic medical record. When the program began in 2015, less than 100 homeless patients had been identified. Using data mining techniques, we have found evidence that since 1997, 10,000 patients may have been homeless. In 2019, we have found approximately 1,700 patients are currently homeless.
Finally, UI Health have come to believe that homelessness is not a failure of the individual, but of systems. The patients in the program had significant interaction with law enforcement, emergency medical services, the courts, jails, prisons, hospitals and social service agencies. UI Health has created a new position, Associate Vice Chancellor for Systemic Social Justice, whose responsibility is to seek alignment and shared priorities among public sectors who have traditionally worked in isolated silos.
What Makes Your Project Innovative?
The Better Health Through Housing Program and its 2.0 version, the Flexible Housing Pool, are innovative because:
1.) It thrusts a hospital into being an active public health participant, taking responsibility for the health of the communities in which it serves;
2.) It acknowledges that housing is a fundamental basic need for health, and without it, it is nearly impossible to manage one's health;
3.) It has re-framed homelessness as a health condition that has profound negative impacts on health and outcomes;
4.) The Flexible Housing Pool necessitates a collective impact model that acknowledges that healthcare and other public sectors must come together to address complicated social issues;
What is the current status of your innovation?
UI Health has housed 59 patients to date, and by next June will have housed a total of 75-80. UI Health are completing their 2nd program evaluation of the 59 that will be published in February 2020 by the Center for Housing and Health. This is a mixed methods approach that will report mortality, morbidity, cost and healthcare utilization, as well as a qualitative quality-of-life survey of the participants.
Additionally, the Flexible Housing Pool will complete its first evaluation by June of 2020 of a total of 150 patients placed into housing by both UI Health, and Cook County Health, the other public hospital in Chicago.
Collaborations & Partnerships
1.) Civil Society Organizations: The Center for Housing & Health developed a network of 27 supportive housing agencies and 3 single room occupancy hotels, offering our patients a choice on where to live.
2.) The Flexible Housing Pool brought together disaggregated sources of funding from government (Chicago, Cook County), philanthropy (JP Pritzker Foundation), insurance companies (Blue Cross), and other hospital systems (Advocate, Northwestern).
Users, Stakeholders & Beneficiaries
1.) Citizens: On all committees, UI Health apply an equity lens and invite participation from individuals with lived experience - those who have been chronically homeless, and those with severe mental illness. Those individuals hold UI Health accountable and inform them on design.
2.) Government: The program brought together government agencies that had never cooperated together before - in fact, they used to hold each other at arm's length.
3.) Civil: Agencies convened stakeholders that discovered shared priorities.
Results, Outcomes & Impacts
In the first cohort of 26 patients, the mortality rate was 34.6% (9/26). The 2nd cohort had a 20.3% mortality rate (12/59) but this was due in part because UI Health did not have the right combination of housing and supports for those with severe mental illness or substance use and thus could not refer them into housing.
Utilization decreased 57% in the first cohort and 45% in the 2nd. Homeless patients had extraordinary rates of chronic diseases, mental illness and substance use disorders, with 64% having hypertension, 68% having asthma or chronic obstructive pulmonary disease, 41% having a kidney disease, 41% having a subcutaneous skin disorder, 39% having an opioid use disorder, and 58% having a serious mental illness.
Challenges and Failures
UI Health found a structural failure. There is a shortage of Assertive Community Treatment (ACT), a community-based intensive intervention for those with serious mental illness, meant their housing retention rate was 47% - still good, but below the ~80% retention rate of the evidence-based Housing First model of care. UI Health also needed access to project-based housing, in multi-unit buildings were there is around-the-clock clinical staff that can provide the additional support to help patients remain in the community, not going from Emergency Room to Emergency Room.
Also, the city has significantly underfunded its crisis shelter system and has been dependent on faith-based organizations to provide crisis shelter services. They cannot be held accountable or auditable because they take no government funding. These shelters are overcrowded and we've noted several patients with mental illness have been banned because they become agitated in crowded conditions.
Conditions for Success
This program and other hospital-based programs, along with collective advocacy from the multiple agencies that are engaged, will lead to increased start-up funding for Assertive Community Treatment providers. Multiple stakeholders from the penal system, police, fire, healthcare, mental health and substance abuse treatment agencies, are now convening to propose a statewide strategic plan for mental health.
Additionally, Emergency Departments at area hospitals are banding together to advocate for Social Emergency Medicine, and will lobby the city to develop an evidence-based policy for its crisis shelters, including low-barrier shelters, an increase in funding (Chicago is 10/10 for per-capita funding of homeless services).
UI Health have found that providing a combination of ethical, medical and fiscal factors, combined with "its the right thing to do" is enough motivation for most public sectors to want to solve this issue.
The Better Health Through Housing program has been replicated by five other hospitals here in Chicago, as well as Boston, Peoria Illinois and St. Louis, Missouri. The Flexible Housing Pool came from a model developed by a joint project between Los Angeles County and the City of Los Angeles.
1.) Homeless needs to be re-framed by healthcare as a dangerous health condition. The irony is that it has the same age-related mortality as some cancers and chronic diseases. While hospitals will go to extraordinary lengths to address patient's medical concerns, the homeless - who have the same mortality risk - get discharged back to the streets.
2.) The homeless are almost invisible in healthcare. Homeless is under-documented by healthcare, largely because we are not compensated for documenting "social" conditions. Yet in UI Health data mining, they have evidence of approx. 10,000 patients since 1997 that may have been homeless. This past year organisers found approx. 1,700 patients who are homeless. Other local hospitals here have found 500, 1,300 and 1,400 in their medical records.
3.) They may have exorbitant cost & utilization: between 30-40% of homeless patients have significantly elevated costs & utilization, ranging from 2.5 to 160 times more expensive that other patients.
4.) To make and impact, hospitals will need to band together and utilize a collective impact approach.
Big data and cross-sector data exchange plays a vital role to be able to identify homeless individuals, and to implement policy changes based upon evidence. The evidence lies locked up in public sector data silos.
- Identifying or Discovering Problems or Opportunities - learning where and how an innovative response is needed
- Evaluation - understanding whether the innovative initiative has delivered what was needed
- Diffusing Lessons - using what was learnt to inform other projects and understanding how the innovation can be applied in other ways
16 September 2020