How we can improve the population health of people experiencing homelessness

Homelessness is a fundamental issue in population health management. People who are homeless typically have a high incidence of chronic conditions, high morbidity rates, and high utilization of emergency department services. The homeless population has traditionally had limited access to  healthcare and what care they receive is fragmented.

However, providing  healthcare to the newly insured—particularly those experiencing homelessness and becoming enrolled in Medicaid—is a central focus of the Affordable Care Act, and as such, large numbers of homeless individuals with complex medical and psychosocial needs are or will be seeking services.

This change in insurance coverage applies to two types of providers:

1) Traditional homeless services providers, such as social service agencies and shelters, that have always served the homeless but haven’t billed Medicaid for services; and

2) Behavioral health providers, who do have experience billing Medicaid but who have little experience addressing the unique issues faced by homeless people.

Historically, there was little business interest—i.e., financial gain—in serving uninsured individuals who were homeless. Now, many efforts are underway enroll homeless people in Medicaid, so providers can get paid and truly contribute to the greater good. However, even if a behavioral health provider can enroll a homeless individual, the lack of housing, social supports and other resources can make serving that individual extremely challenging.

Adding to these issues is the impact of the chronic stress experienced by the homeless. Violence, poverty, poor nutrition, lack of sleep and many more social determinants of poor health result in toxic stress, increasing the risk of medical conditions like heart disease and diabetes. The relationship between homelessness and poor health led the Harvard School of Public Health to declare that “housing is  healthcare.”

The problem

How can providers build or become a part of health and social service systems that can effectively serve this population? Partnerships between housing and behavioral health providers is the key. Medicaid-billing behavioral health providers who are enrolling newly insured clients need to consider any or all of the following options:

1) New programming specific to homeless needs;

2) Resources to address chronic and co-morbid health conditions; and

3) Partnerships to provide holistic services—including housing—to this population.

The solution

So what can you do today to start serving homeless individuals? Behavioral health providers need to engage with homeless services providers and advocate for partnerships to make it work. Health economists tell us that housing costs less than homelessness and unmitigated disease and disability. Housing is an essential part of treatment for both mental health and physical health conditions. This can be as simple as approaching your colleagues and the local shelter and brainstorming ideas on how you can serve their clients and vice versa, to participating in the development of an evidence-based program, such as Housing First and Rapid-Rehousing. These programs quickly move people from shelters to stable housing by removing barriers.

The STAR apartments in the skid row district of Los Angeles are an example of a successful partnership between housing/homeless care providers and behavioral health services. This innovative housing complex for chronically homeless people includes the county Department of Health Services’ Housing for Health division headquarters and a county medical clinic on the ground floor.

Partnerships between housing and homeless providers and behavioral health providers are one way to improve population health. Clinicians, executive leadership and advocacy groups together can build partnerships that focus on getting the homeless housed while providing needed support via integrated care and care coordination.