5 Ways We Have to Change Healthcare Delivery for the Homeless

In the 1990s a radical shift occurred in the approach to delivering services to persons suffering with homelessness. Now known as “Housing First,” these programs officially recognized the power of Abraham Maslow’s hierarchy of needs by flipping the homeless housing paradigm on its head. Until Tsemberis and colleagues broke the mold with their randomized controlled trial of supported housing in New York City,¹ the status quo demanded sobriety, papers, and legitimacy before the keys to an apartment were turned over.

[[{"type":"media","view_mode":"media_crop","fid":"47812","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2042589270543","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5666","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 8px; height: 263px; width: 400px; float: right;","title":"©crazystocker/Shutterstock.com ","typeof":"foaf:Image"}}]]Housing First delivered immediate occupancy, permanent supported housing to persons directly off the street, with virtually no strings attached. Housing supports included intensive interdisciplinary outreach teams, and the requirement that persons living in the “supported” housing at least open the door once a week for a check-in. Wildly successful in reducing homeless recidivism compared to care as usual at the time, these programs have now been shown to be effective in a variety of settings (urban, rural, etc), and are the standard of housing services globally.

In one of the only studies of mortality among Housing First participants, Henwood and colleagues observed, in Philadelphia, a fascinating and yet not surprising shift in disease burden. Cardiovascular disease, which accounts for ~15% of total mortality in typical homeless populations, doubled among the persons housed, with the bulk of deaths occurring shortly after transition to Housing.² Henwood et al call for expanded healthcare intervention that targets cardiovascular risk in this particularly vulnerable population.

As communities embrace the Housing First model, we must also radically re-think how we deliver all of our healthcare services. Using reduction of cardiovascular disease risk as an example, here are five ways our thinking and our behavior need to shift:

1. Drop the “street medicine mobile clinic” philosophy. Mobile clinics serve acute care needs best and are expensive to maintain. Once housed, the rates of acute injury, infection, and other urgent care issues among residents drop, and chronic non-communicable diseases take over. Hypertension, diabetes, cigarette smoking, obesity, cholesterol – none of these modifiable risks for heart disease require an exam room, ophthalmoscope or printer to manage. They are chronic conditions, and need a chronic care system. When urgent care needs arise, transport people to the growing plethora of urgent care clinics where their needs can be addressed.

2. Prioritize engagement, education and enhancement of intrinsic motivation. Trauma robs individuals of their agency over life. By the time a chronically homeless person is housed, they often lack the capacity to envision life beyond the end of the week. New healthcare teams must be gifted in motivating healthy choices attached to revitalized hopes and goals. Sometimes this is innate, often it is not. Motivational interviewing and practicing in the “recovery” framework are definable skillsets many in the healthcare delivery system give lip service to, but fail to fully embrace.

[[{"type":"media","view_mode":"media_crop","fid":"47813","attributes":{"alt":"","class":"media-image media-image-right","height":"279","id":"media_crop_4654296913902","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5667","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 8px; float: right;","title":"©PureSolutions/Shutterstock.com ","typeof":"foaf:Image","width":"275"}}]]3. Track outcomes and intensify treatment for those who fail to meet targets. A healthcare system must not reflect the chaos inherent in the lives of persons it seeks to help. We can protect against this by focusing our services on measurable outcomes we can change. Fortunately, we have validated outcomes for screening, diagnosing and tracking diabetes control (Hgb A1c) and blood pressure – leading risk factors for heart disease. If we can establish registries and monitor individuals’ clinical status, periodic team check-ins can prioritize those who haven’t been able to engage in their care or achieve their disease management targets; then, we can intelligently intensify outreach and treatment until those outcomes are met. We can’t shorten this cardiovascular mortality gap any other way.

4. Invest in a team from square 1. Chronic illnesses require a team to engage, educate, and deliver evidence-based care. All components of that team, from the physician/prescriber/provider to community outreach worker to nurse to case manager must have regular time together to think creatively about the population to which they are responsible. If someone is missing from that meeting, your system will only be as good as your weakest link.

5. Truly integrate behavioral health and primary care. The highest form of integrated care occurs when a seamless treatment plan is assimilated in real-time by a proactive treatment team with an informed and activated patient. This can be facilitated by measuring and tracking mental health outcomes (depression, PHQ-9 scores) alongside physical health outcomes (eg, Hgb A1c). Getting a leg up on heart disease is impossible without recognizing the direct and indirect toll of behavioral health morbidities on vascular outcomes.

These shifts simply reflect the need to morph our healthcare delivery system to one of chronic care management, health promotion and prevention first, with episodic and urgent care needs second. Without these changes, we’re spinning our “mobile clinic” wheels and we’ll miss repeated opportunities to realize the promise of Housing First: the chance for a homeless individual to pursue a full, long, and healthy life, just like the rest of us.
 

References:

1. Tsemberis S, Eisenberg RF. Pathways to housing: supported housing for street-dwelling homeless individuals with psychiatric disabilities. Psychiatr Serv 51: 487–493, 2000.

2. Henwood BF, Byrne T, Scriber B. Examining mortality among formerly homeless adults enrolled in Housing First: An observational study. BMC public health 15: 1209, 2015.