On cold winter nights, Derrick Lyons would often go to the emergency department (ED) at John H. Stroger, Jr. Hospital of Cook County in Chicago, not because he was acutely ill, but because he needed a warm place to sleep.
Lyons, now 61, does in fact suffer from uncontrolled diabetes and high blood pressure — chronic conditions that frequently landed him in the hospital. But he also suffered from chronic homelessness, and after a few cold nights sleeping in the park, or in an abandoned building or car, he would find himself heading for the one place he knew he’d find an empathetic reception.
“Some of the nurses were nice, because I was going so much, they just let me sleep on one of the stretchers,” Lyons recalls. “In the morning, then I had to leave.”
All of that changed three years ago, when Lyons was contacted by a housing specialist with the Flexible Housing Pool, a program of Chicago’s Center for Housing and Health that helps patients who are frequent users of the city’s health and judicial systems to find permanent housing. Since 2020, the program has offered permanent housing to 527 people, including Lyons.
“Physicians have said to us they get really frustrated when the same patient who has very treatable conditions keeps coming back [to the hospital], especially since their whole job is to keep people well,” says Peter Toepfer, executive director of the Center for Housing and Health, which administers the Flexible Housing Pool and acts as the liaison between its health care and housing partners.
The Flexible Housing Pool is just one of several initiatives supported by academic and other health systems across the country that aim to improve the health of their most vulnerable patients by addressing one of the root causes of poor health: homelessness.
“How people are doing in life, how they’re thriving or not thriving often has a lot to do with their housing situation,” says Rebecca Clay Christensen, executive director of community health at Bon Secours Richmond, which has provided $8 million in affordable housing grants over the last 10 years in the greater Richmond, Virginia, area. “A person who is adequately housed has a great opportunity to deal with all the other things that aren’t working out so well,” including their physical and behavioral health needs.
The relationship between housing and health
The relationship between inadequate housing and poor health is well established. People who suffer from chronic homelessness have a shorter life expectancy as well as starkly higher rates of many chronic illnesses, including HIV, diabetes, hypertension, depression, hepatitis C, and substance use disorders. While poor health is sometimes a cause of homelessness, the state of being homeless can create new health problems or exacerbate old ones, according to the National Health Care for the Homeless Council.
People who suffer from homelessness can also be heavy users of the health care system, particularly the ED. The Centers for Disease Control and Prevention estimates that between 2015 and 2018, there were 203 ED visits per 100 homeless persons, compared to 42 ED visits per nonhomeless persons.
More than three quarters (86%) of all ED visits by individuals experiencing homelessness were to teaching hospitals, according to a 2017 statistical brief published by the Agency for Healthcare Quality and Research that examined data from eight states. That included 73,600 visits during which patients were “treated and released,” as well as 110,200 visits that resulted in admission to the hospital.
“How people are doing in life, how they’re thriving or not thriving often has a lot to do with their housing situation.”
Rebecca Clay Christensen
Bon Secours Richmond
Because many health systems’ most frequent users are homeless, academic and nonacademic hospitals have long partnered with housing agencies in their respective jurisdictions to identify patients in need of stable housing and to work with those patients to secure a permanent place to live.
In Baltimore, Bon Secours Mercy Health has developed more than 800 affordable housing units, with access to resident services coordinators who can help residents schedule doctor’s appointments, apply for public assistance, and access preventive health services like vaccines and screenings, says George Kleb, executive director of Bon Secours Community Works. Although Bon Secours sold its Baltimore hospital to LifeBridge Health in 2019, the health system continues to invest heavily in its housing and community development program, as well as other programs including job training, tax preparation, youth and family services, and more.
A 2021 paper in Health Affairs spelled out the impact of the Bon Secours program, specifically its social return on investment (SROI), finding an SROI of between $1.30 and $1.92 for every dollar of annual operating expense. The SROI includes such factors as reduced resident visits to the hospital due to environmental hazards and better medication management.
For Megan Sandel, MD, a pediatrician at Boston Medical Center (BMC) and principal investigator at Children’s HealthWatch, a nonpartisan network of children’s health researchers and policy experts, the benefits of stable housing go far beyond dollars saved. In a 2017 JAMA paper, she notes: “The return on investment involved in expanding affordable housing cannot be fully measured by portfolio profits or even by costs saved by addressing the root causes of residentially insecure families’ health needs. It is also measured by building healthier communities — with plenty of safe, decent, and affordable housing — to improve the well-being of children who, if nothing changes, may be the future’s most expensive patients.”
As recognition of the link between health and housing has grown, health systems have taken a variety of approaches to address housing insecurity.
BMC has a long history of partnering with local community organizations to address homelessness. In the mid-1980s, hospital administrators noticed that many of Boston’s frail elderly were being displaced from their apartments. Working with the Boston Housing Authority, the hospital established the Elders Living at Home program in 1986 to assist these vulnerable patients, providing intensive case management and housing assistance. Since that time, the program has helped more than 2,000 homeless elders find permanent housing.
Building on the success of that program, BMC has since expanded its efforts to assist the city’s unhoused population. Since 2017, the hospital system has invested more than $6.5 million in affordable housing initiatives, partnering with the Boston Housing Authority, Cambridge Housing Authority, and Boston Health Care for the Homeless Program; community development organizations including Nuestra Comunidad Development Corporation, Madison Park Development Corporation, and Codman Square Neighborhood Development Corporation; and affordable housing developers including The Community Builders, among others.
“If you don’t have a stable, decent, affordable home, then most of the health care interventions that we would typically provide just don’t work as well,” Sandel says. She gives as an example a person with heart failure, for whom the primary treatment might be diuretics — medications that prompt a person to urinate more frequently to get rid of excess fluid so the heart doesn’t have to work as hard. Someone without stable housing might not have frequent access to a bathroom, and so might choose not to take the medication, which results in them becoming sicker and ending up back in the hospital. “I sometimes joke that we house people very effectively,” Sandel says. “We just house them in the most expensive places, like inpatient units and emergency departments.”
“I sometimes joke that we house people very effectively. We just house them in the most expensive places, like inpatient units and emergency departments.”
Megan Sandel, MD
Boston Medical Center
At Denver Health, hospital leaders have partnered with the Denver Housing Authority to design a program that will provide more immediate assistance to patients experiencing homelessness. In 2020, the hospital sold a little-used office building on its campus to the housing authority, which is converting it into low-income housing for seniors, but the plan also includes one floor of units designed to house patients experiencing homelessness who need transitional care until more permanent housing can be found.
“We really care for a large population of patients who are extremely vulnerable and who have high medical needs who are experiencing homelessness,” says Sarah Stella, MD, a Denver Health physician and the lead clinical partner for the project.
In fact, hospital data show that 20% of Denver Health’s patients in 2022 were experiencing homelessness, while another 22% were experiencing housing insecurity (trouble paying rent, spending the bulk of their income on housing). Of the top 50 most frequent users of its ED in 2022, 83% were experiencing homelessness, Stella says.
“This program is really designed to support those patients who maybe come into the hospital for an acute problem like pneumonia, but then don’t have a safe place to go to recover,” Stella says. “There are a subset of our patients who really just need four walls and the right kinds of supports to help them transition from the hospital to a longer term, more stable living situation. The goal is really to decrease the length of stay … but also decrease rehospitalizations and ultimately get them connected with longer term housing.”
Denver Health has also partnered with the Colorado Coalition for the Homeless to lease recuperative care beds at the Stout Street Recuperative Care Center for patients in need of a higher level of care than transitional housing. That initiative has already started to pay off. In addition to providing a safe place for patients to recover from acute injury or illness, the hospital has estimated that for every five beds it leases, the hospital system will save nearly $1 million per year.
“We really care for a large population of patients who are extremely vulnerable and who have high medical needs who are experiencing homelessness.”
Sarah Stella, MD
Saving money, saving lives
In 2015, the University of Illinois Hospital and Health Sciences System in Chicago invested $250,000 in a pilot program through which patients who were chronically homeless and frequent ED users would be able to get temporary housing until more permanent housing could be found.
Called Better Health Through Housing, the program was so successful that it reduced hospital costs by 42% for the first 15 patients who enrolled in the program, according to Stephen Brown, director of preventive emergency medicine and program director for Better Health Through Housing.
UI Health has now contributed $1.5 million to the program, and also partners with the Center for Housing and Health's Flexible Housing Pool to identify patients experiencing housing insecurity. The hospital estimates that ED and inpatient utilization has decreased by 41% and 52%, respectively, as a result of the program.
"Homelessness is primarily a failure of a set of complex systems that do not work together in a cohesive manner," Brown says. "It is not a moral failure of the people trapped in them."
When Derrick Lyons was first contacted about the Flexible Housing Pool, he was so skeptical that he intentionally missed his first appointment with his designated housing specialist. "The first time, I didn't show up because I thought it was a scam," he says. "I thought, 'These people are trying to rob me.' So they called me again to set up another interview. I thought, 'Well, maybe I'll go because it's at McDonald's, and they do have security there.'"
Three months later, Lyons moved into his own apartment. He went back to college at Chicago State University and is working on a degree in sociology, with the goal of becoming a social worker working with people experiencing homelessness.
With stable housing, his health has also improved dramatically. “I take my medications regularly. I go to the doctor regularly. I have a doctor and we’re on a first-name basis,” he says. “My diabetes is under control.”
Toepfer says Lyons’ good health now is no accident. The Flexible Housing Pool team works with its health care partners not just to secure housing for frequent ED patients, but also to ensure those patients don’t end up back in the hospital. To that end, they invite hospital representatives to be part of case conferencing meetings, and they follow up to ensure that patients are showing up for doctors’ appointments and taking their medications.
“The goal is to stop that cycle of people ending up in the hospital again and again,” Toepfer says. “We certainly believe that homelessness is both preventable and treatable. It’s a matter of priority and resources and political will.”