Friday, September 19, 2014
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There's no place like home in health care: Housing the homeless is key to controlling costs

What remains outside our offices in Camden, NJ is exposed wet dirt: the patches of grass are faded from use, and the exposed brown ground has developed puddles, seeping up the water from a rainy day. Two weeks ago, New Jersey state and county officials cleared up the tents that housed homeless individuals once living there, displacing nearly 100 vulnerable individuals from their self-protected safety net for life on the streets: blue, plastic tents.

There’s no place like home in health care: Housing the homeless is key to controlling costs

What remains outside our offices in Camden, NJ is exposed wet dirt: the patches of grass are faded from use, and the exposed brown ground has developed puddles, seeping up the water from a rainy day.  Two weeks ago, New Jersey state and county officials cleared up the tents that housed homeless individuals once living there, displacing nearly 100 vulnerable individuals from their self-protected safety net for life on the streets: blue, plastic tents.

New Jersey spent more than $300,000 to evict people from their makeshift homes, nearly half the amount of money it would take to provide permanent housing and supportive services for thirty individuals over the course of a year.  While some have ended up in shelter beds, a temporary “band-aid” to the problem, many others have been displaced from their communities, sleeping instead in abandoned buildings, moving under different highways, and seeking care in expensive hospital beds.

The destruction of tent city without any real planning or the provision of appropriate resources is unconscionable.  There are alternatives.  Cities and states around the country are investing in evidence-based solutions to homelessness that can permanently eliminate this human tragedy.  Salt Lake City, Utah, and Phoenix, Arizona have ended chronic homelessness among veterans through a Housing First approach, proving that ending homelessness is possible and has bipartisan support. Homelessness does not need to exist in Camden, just as it doesn’t need to exist in Lower Merion or Philadelphia.

An approach called Housing First has been adopted throughout the country and its use is credited with the reducing chronic homelessness by 25 percent in seven years.  In just three years, homelessness among veterans has declined by 24 percent.  In randomized control trials, more than 84% of individuals remain stably housed through a Housing First model. In contrast, under the older housing model of “graduating out of shelters,” only 30 percent remained stably housed.

In Housing First, a homeless individual is immediately placed into permanent housing and given the support services needed to stay.  Individuals are accepted into housing regardless of sobriety, active substance use, criminal background, or credit history.  Housing First works for the most vulnerable, long-term, or hard-core homeless individuals, who happen to generate the most costs across systems including expensive hospitals, temporary shelters, psychiatric hospitals, and jails.

By targeting the most expensive individuals, cities, counties, and states are generating tremendous net savings.  It’s estimated that the public saves $10,000 for every tenant housed in permanent supportive housing.  Had all of these individuals been placed into permanent supportive housing using the Housing First model, the net savings would have totaled nearly $1,000,000.

Across the river, Philadelphia is leading the way in reducing homelessness through Housing First.  Mayor Nutter recently signed on in the national campaign to eliminate veteran homelessness, joining Mayors across the country. New York has gone so far as to invest Medicaid dollars in building supportive housing on the Housing First model to save health care costs.

Why does Housing First work?  First, Housing First acknowledges that the primary safety and security of an individual comes first, regardless of substance use or criminal history.  Housing gives an individual the space to address issues of early childhood trauma, mental illness, substance use, or other factors that contribute to their homelessness.  In terms of cost savings, Housing First works because it targets the most difficult and most expensive, those with chronic disease, complex social issues, mental illness, and substance use, and dramatically reduces their reliance on expensive emergency institutions like hospitals, jails, and shelters.

No amount of medicine is going to truly fix a person sleeping on a park bench.  These individuals will continue to cycle in and out of the emergency department and hospital wards because their basic needs are not being met.  In Camden, we have found that 1 percent of patients account for 30 percent of all healthcare costs.  Nearly 30 percent of the highest users are unstably housed.  For them, there is little that can be done to change their use of the healthcare system until they receive permanent housing.

To solve the challenges of ballooning health care costs, we need to tackle even harder social problems, like housing.  In Trenton, one homeless woman visited the hospital 450 times in a single year, generating over 1 million dollars in costs.  After placement into a Housing First program, yearly visits dropped down to 12, saving hundreds of thousands of dollars.  Camden lacks any Housing First program targeted toward expensive and frequently admitted patients.  As a result, hospitals in Camden have lost tens of millions of dollars annually from uncompensated care.

As the Affordable Care Act (ACA) provides insurance to more individuals, leaders in hospitals, cities, counties, states, and the federal government need to seriously consider the cost of not paying for Housing First.  Without it, we will find ourselves with a truly unsustainable healthcare budget and the needless suffering of our fellow citizens.

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Elizabeth Buck is a Program Manager for Policy and Advocacy at the Camden Coalition, where she works to improve housing options for high-utilizing patients of the healthcare system in Camden.

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Robert I. Field, Ph.D., J.D., M.P.H. Professor, School of Law & Drexel School of Public Health
Jeffrey Brenner, MD Founder of the Camden Coalition of Healthcare Providers, Medical Director of the Urban Health Institute at Cooper University Healthcare
Andy Carter President & CEO, The Hospital & Healthsystem Assoc. of Pa.
Robert B. Doherty Senior Vice President of Governmental Affairs & Public Policy American College of Physicians
David Grande, MD, MPA Assistant Professor of Medicine at the University of Pennsylvania
Tine Hansen-Turton Chief Strategy Officer of Public Health Management Corporation
Drew A. Harris, DPM, MPH Director of Health Policy Program at the Jefferson School of Population Health
Antoinette Kraus Director of the Pennsylvania Health Access Network
Laval Miller-Wilson Executive Director of the Pennsylvania Health Law Project
David B. Nash, MD, MBA Founding Dean of the Jefferson School of Population Health
Mark V. Pauly, Ph.D. Professor of Health Care Management, Business Economics and Public Policy at The Wharton School
Howard J. Peterson, MHA Managing Partner of TRG Healthcare, a national healthcare consulting firm
Donald Schwarz, MD, MPH Deputy Mayor for Health & Opportunity and Health Commissioner for the City of Philadelphia
Paula L. Stillman, MD, MBA Healthcare consultant with special expertise in population health and disease management
Elizabeth A. W. Williams Senior Vice President & Chief Communications Officer for Independence Blue Cross
Krystyna Dereszowska A third-year law student concentrating in health at Drexel
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