Every physician knows the feeling of failure despite providing the best medical care. George was my example. George was brought to HCMC’s Emergency Department (ED) with a severely broken jaw after being assaulted at a transit station, but our staff quickly discovered that he had also been drinking heavily to numb his physical pain. Because George needed his jaw reconstructed, I became George’s surgeon, and our team repaired his fractured mandible. Although patients with an isolated mandible fracture are usually discharged a day or two after the repair, this was not possible for George, because he is homeless. Where do we send a postop patient experiencing homelessness? Shelters would not take him due to his medical complexity after surgery, so George needed to stay at HCMC until we found him a place to live. Catholic Charities, an amazing partner of HCMC, welcomes patients experiencing homelessness to recover from their illness or surgery at Exodus Residence.
Everyone was thrilled by the news that we had found a place for George to recover—everyone but George. For reasons that are still not clear, he was not willing to go to Exodus Residence to recover. He left the hospital Against Medical Advice (AMA), and I have not seen him since. But he has visited the ED about once a week since that time, usually brought in for intoxication. George had the best surgical treatment we have to offer, but addressing his acute problem was not enough.
What was missing? George could improve many aspects of his life, but he lacked one key social determinant of health: stable housing. Without this basic necessity, how could George ever hope to address his other health concerns? This fundamentally unequal starting place—the fact that George starts every day on the streets—perfectly illustrates the health disparity created by homelessness.
The consequences of this disparity are staggering: in a 2014 paper describing homeless deaths in British Columbia titled “Dying on the Streets,” Condon and McDermid report that, in cold climates, homelessness can cut a person’s life almost in half.
Prescribing—and paying for—housing
The evidence-based literature shows that housing is an effective health intervention, but we, as providers, are frustrated by our inability to deliver that treatment. We want the ability to “prescribe housing.” To begin the journey towards that objective, Upstream Health Innovations (UHI), the innovation team for Hennepin Healthcare, asked the question: how might we prescribe housing to those who need it?
To move George and others like him from our hospital directly into stable housing, we presumed that the health care system would need to pay for at least a portion of that housing. The notion of a health care system paying for housing initially seems nonsensical, because budgets are already stretched to the limit by existing services. But the truth is that the health care system already pays to house the homeless in settings like the ED and hospital. The total charge for George’s three-day hospital stay was $93,000.
Fortunately, an opportunity exists to redirect this acute care spending to pay for housing, and the literature shows that housing the highest-utilizing patients creates health care savings. We also believe that providers will be more incentivized to do this when we move closer to value-based payment models that pay us to keep people healthy.
How much should housing cost?
For health care to pay for housing, we needed to flip the standard model of building affordable housing. Traditional affordable housing projects start with the building design and then work backwards to raise the money. We flipped that model by starting with the dollars that are available and then designing the structures and services within that budget. In collaboration with the University of Minnesota School of Public Health, we interviewed every Medicaid health plan in Hennepin County, housing experts in every level of government, community partners who serve the homeless, and subject matter experts at HCMC.
We estimated the expected health care savings from housing and reinvested all of those savings into the model, because most health plan leaders told us that they would need no return on investment from housing—just a solution that was cost-neutral, given the expected reduction in ED visits and hospitalizations. What health plan leaders really wanted from housing was dramatically improved health outcomes for their members. In addition to health care funding, the model also utilizes a reliable source of funding from the state of Minnesota. Finally, the model includes funding for supportive services to help individuals remain successfully housed. From this financial modeling, we learned that we would need to build and operate housing—and pay off the mortgage in five years—for less than $995 per month.
Traditional affordable housing exceeds that monthly threshold. UHI, along with Thomas Fisher, MA, a professor at the University of Minnesota and director of the Minnesota Design Center (MDC), and his team, explored architectural innovations that could help the health care system house patients experiencing housing instability. We quickly learned that both existing affordable housing units and standard new construction techniques are too expensive for the health care system to afford and won’t meet our $995 price point with a five-year mortgage payoff. We need something beyond what we currently consider “affordable”—we need “extremely affordable” housing. Extreme affordability can be achieved through many strategies, including a smaller footprint using micro-units, shared resources, energy efficiency, new building practices, and innovative methods of property management.
A surprising key ingredient for success
Many groups across the country use these micro-units—minimally sized dwellings, sometimes single-room structures—to house people experiencing homelessness, and we wanted to learn from these communities. We visited Community First Village (CFV), a tiny home village successfully serving the chronically homeless in Austin, Texas. We saw all the standard ingredients you would expect: affordable housing, supportive services, medical care, mental health treatment, chemical dependency services, and vocational training.
But CFV demonstrated that the essential ingredient to remain successfully housed is a supportive community. During our interviews, we met many people who had previously obtained traditional affordable housing, but later ended up returning to the streets. Recall how we obtained a stable place for George to recover after his surgery, but that he chose to return to the streets after leaving AMA. Why would people turn down a stable place to live? Many of our patients have shared that they do not want to go to a place where they feel isolated from their loved ones or rejected by their new neighbors. At CFV, social connections are woven into every aspect of village life, so that residents participate as an integral part of the community and know that CFV is their home. The success of CFV taught us that we need to not only build extremely affordable housing, but also to design an intentional community with supportive neighbors.
Pat, a woman who lives at CFV and struggles with bipolar disorder and cutting behaviors, showed me what “community” really means. Pat’s neighbors know her cutting behaviors start small and can escalate over time. But her neighbors also know that the first sign of trouble is when she cuts her hair. When one of her neighbors sees that she has taken a chunk out of her hair, the community rallies around her, and they also let the mental health center know. That support has always helped her to avoid more harmful behaviors. “Community” is really a dense network of people and social connections that accept you as a person—even your self-injuring behaviors—and rallies around you with acts of kindness, expressions of concern, and offers to help.
With this insight that both housing and intentional community are necessary parts of the prescription, “Envision Community”—a collaborative project under development by Upstream Health Innovations, the University of Minnesota, and community organizations—was created to cultivate health through housing and community. In addition to featuring supportive micro-units that are truly affordable, we are also designing the social connections all of us need to make a place home. Our collaborative is holding targeted co-creation sessions to learn what types of political, financial, and community barriers exist, and how to overcome them. We are seeking partners with insights into these barriers to join us in designing and funding a pilot of Envision Community in Minnesota.
The bottom line
Health care providers know that housing is an important social determinant of health, and we long to provide housing for our patients by writing a simple prescription. The complexity of the situation is best captured by the stories of people who were placed in stable housing but ended up returning to the streets. We have learned that the dense social connections of a community are the key component that keeps people in stable housing. As health care systems look at ways to house their patients, they also need to evaluate whether their patients will be living in a place with intentional social connections. Join us as we design a system where we can write a prescription for both housing and intentional community.
William E. Walsh, MD, is the deputy chief innovation officer for Hennepin Healthcare’s Upstream Health Innovations. He is also a board-certified and practicing facial plastic and reconstructive surgeon and an assistant professor in the Department of Otolaryngology–Head and Neck Surgery at the University of Minnesota.
Jon L. Pryor, MD, MBA, is the chief executive officer of Hennepin Healthcare and is a board-certified urologist. He is also a professor in the Department of Urologic Surgery at the University of Minnesota.
By William E. Walsh, MD, and Jon L. Pryor, MD, MBA, Jun 25, 2018
Article Source: https://issuu.com/mppub/docs/mp_0618_web