Health and homelessness – the power of working together

Photo: © Janian Medical Center for Urban Community Services

Healthcare sessions provide opportunities to recognise the signs that someone is struggling to keep their home or that the condition of their housing is causing ill-health.

Bart was 34 and working as a security guard when he was admitted to hospital with acute myeloid leukaemia.

“I had no savings and was on the minimum wage. I had been staying with a friend, but was not able to return there because my friend was afraid that he might ‘catch’ the cancer.”

– Bart, one-time homeless person

Bart had to undergo chemotherapy, which meant repeated visits to the hospital. However, he had nowhere to live. The London borough where he had previously lived was reluctant to house him, despite his medical reports.

There are many cases such as Bart’s. Bad housing conditions, homelessness and poor health are intrinsically linked and it is well known that poor health is both a cause and a result of homelessness.

The complexity of providing quality healthcare to the homeless is the reason why the fields of homelessness and health need to find ways to work together. As it is, the healthcare system and homeless organisations are set up to work separately from each other. This hampers the possibility of reaching the most vulnerable. Medical professionals do not know the housing status of their patients, which limits the scope for intervention. In addition, it is difficult to provide ongoing healthcare to the homeless or those in danger of losing their homes.

A lack of joined-up working across sectors has often been cited by politicians and policy-makers as a fundamental barrier to resolving social problems. In 2013 the Minister of State for Care and Support, Norman Lamb, said, “People don’t want healthcare or social care, they just want the best care.”

“Working together produces better outcomes for people,” said Amanda Beswick, Director of Oak’s Housing and Homelessness Programme (HHP). “Yet there are some clear barriers to achieving this common-sense logic, both structural and cultural.”

Oak funds initiatives that work to strengthen the links between the homelessness sector and health providers. These include Pathway, which helped Bart, mentioned above, find a home.

Integrated working across government agencies or between not-for-profit organisations is a common theme running through HHP grant-making. Oak sees firsthand the challenges and the benefits when services work together. We asked our grantees some important questions about their work. Read on to find out what they are doing to link the two sectors of housing and healthcare.

Can health providers detect early signs of housing distress?

People at risk of losing their home are not always that easy to reach. Medical appointments are one way to make contact with people who do not use other services – they provide a window of opportunity to talk through issues that contribute to people’s ill health, such as poor housing. Healthcare sessions can provide ways to recognise the signs that someone is struggling to keep his or her home, or that the condition of a person’s housing is contributing to their ill-health.

The Govan Law Centre (GLC), based in Scotland, provides free legal services to people on low incomes for housing, debt, discrimination, education, employment and welfare.

GLC has established weekly Rights Hubs in the four main psychiatric hospitals in Glasgow. These Hubs help the most vulnerable and marginalised people in the city find out about their rights in regard to welfare benefits, debt and housing. In this way, GLC strengthens referral routes between mental health services and homelessness prevention services across the city.

“Our work is clearly having a positive impact on patients. This is in terms of resolving housing and related issues, but also in terms of health, wellbeing, recovery and discharge.”

– Alistair Sharp, Govan Law Centre

“A key factor to our success was having someone champion our cause,” said Alistair. “In this case, it was one of the National Health Services’ mental health service operational managers – he certainly opened doors for us. He saw the immediate benefit and impact of our work with patients. We developed a shared vision of how benefits could be expanded across other psychiatric hospitals in the Glasgow area.”

The Boston Medical Center has always had a progressive view on homelessness. It is one of Boston’s largest hospitals and has, for many years, helped homeless people with medical problems.

Its Elders Living at Home programme identifies housing problems that may put older patients at risk of becoming homeless. It then partners with the Medical Legal Partnership to help resolve these problems so that clients can overcome barriers to securing and maintaining suitable, permanent housing.

“The key to success has been educating medical providers about all of the challenges that their patients, particularly their low-income patients, face in their daily lives. We help them understand how a lack of housing or very unstable housing impacts on their patients, and can undermine their health no matter how many health interventions the providers attempt. They appreciate the programme because it makes them better, more effective practitioners, and they see that their patients have better results. They are now starting to embrace the approach on a policy level as well.”

– Eileen O’Brien from the Boston Medical Center.

Does the US Affordable Care Act provide an opportunity for better links between housing and health? Longterm or “chronically” homeless people are among the highest users of medical care in the United States and are also some of the costliest patients. They often rely on expensive emergency room visits. Permanent supported housing which specifically targets chronically homeless people can both successfully house these individuals and dramatically reduce their need for healthcare. The Affordable Care Act broadens the remit of Medicaid by making it possible to integrate housing support and health services. However, the reality of this work is challenging.

The Supportive Housing Network of New York (SHNNY) works to ensure that there is an adequate supply of supportive housing in New York City. One of its key themes in the coming years will be supporting its members to manage the implications of the Affordable Care Act.

“The Affordable Care Act opened the door for the possibility of Medicaid to pay for a portion of critical services in supportive housing,” said Laura Mascuch from SHNNY. “This will help keep the most vulnerable people in New York housed. SHNNY is working to ensure that this potentially positive resource does not undermine the integrity of the supportive housing model, but instead adds to our community’s ability to offer person-centred housing to New York’s most vulnerable homeless people.”

The Massachusetts Housing and Shelter Alliance (MHSA) works to secure Medicaid funding to cover the costs of health services for people living in supportive housing in Massachusetts.

“The greatest challenge in developing permanent supportive housing is the need to stress its importance in the healthcare of long-term disabled homeless persons without totally medicalising the issue of homelessness,” said Joe Finn from MHSA. “The way to overcome this is by highlighting as key outcomes the importance of social issues, housing, nutrition, education and income.”

The Center for Urban Community Services (CUCS) provides supportive housing in New York City. The Janian Medical Center was established by CUCS in 2011 to carry out psychiatric outreach work and expand CUCS’s services to include primary medical services for homeless people.

“Their bedside manner is beautiful. If you forget, they call your apartment, they make sure you remember… It’s beautiful. I don’t feel like my doctor is here just for the pay-cheque. It’s like she’s here for the people.”

– Moira, CUCS client

Early evidence from the initiative shows that integrating healthcare and supportive housing leads to reduced hospital admissions, improved physical and mental health and fewer visits to the hospital emergency room.

“The Affordable Care Act has introduced a storm of philosophical and programmatic changes in a very condensed timeframe. Our biggest challenge is to fund operations while protecting person-centred care in a way that works for both clients and clinicians.”

– Tony Hannigan from CUCS.

Source: Oak Foundation Annual Report 2015