Homelessness is a wide-reaching and challenging social problem in communities across the United States. The lack of housing is often accompanied by chronic health conditions and overwhelming care costs due to unnecessary emergency room utilization and hospital admissions. Many homeless individuals struggle with at least one substance abuse problem, one chronic physical condition, and a psychiatric illness. Any one of these is preventable or manageable … on its own. But in combination treatment is often inconsistent, the problems become compounded, and all too often, fatal.
The ongoing national discussion around the transformation of healthcare has created unprecedented opportunities for providers of homeless services to collaborate. In many communities, local homeless continuums of care (CoC) are joining forces with health providers, such as Federally Qualified Health Centers, to connect their HMIS to primary care and substance use disorder providers. According to the HUD 2014 HMIS Data Standards Manual, “Solid data enables a community to work confidently towards their goals as they measure outputs, outcomes, and impacts.”
In 2015, the Department of Housing and Urban Development (HUD) started a program called the Housing-Healthcare Integration (H2) Initiative. Twenty communities were selected to receive help in planning and designing a plan of action for integrating healthcare and housing systems and services. Here are a few examples from some of these action plans:
- Standardize tools related to vulnerability/acuity on regional basis so that providers are using same criteria in the same way – thereby providing standard assessment regardless of where the assessment is done
- Link health care providers (especially FQHCs, hospitals, and free clinics) to coordinated entry systems or HMIS
- Conduct analysis of VI-SPDAT score vs. score by healthcare providers with their assessments of claims data
- Strengthen links between homeless individuals and available housing, supportive services, and healthcare through outreach, engagement, and education
- Promote effective care coordination and case management that jointly focus on housing stability and improved health
- Promote statewide implementation of housing navigator and health home programs that link health and housing systems of care
- Move toward cross-system data matching across health, housing, and other services
- Create healthcare coordinating committee with the CoC to coordinate with healthcare system (e.g., hospitals and mainstream medical and behavioral health systems, MCOs)
- Facilitate system-level move from agency-specific case managers working with clients to a system of interdisciplinary teams of care coordinators
In order to help other communities create housing-healthcare integration strategies, HUD published some lessons learned from these 20 communities. Here are a few:
- Conduct frequent user data matches across systems (e.g. homeless assistance, criminal justice, healthcare) to demonstrate need for collaboration and identify the most vulnerable individuals
- When possible, leverage large ongoing efforts, such as Coordinated Assessment/Entry systems, as part of your state or community structure
- Leverage support of Federal Partners, such as:
- HRSA: Build or improve relationships between Federally Qualified Health Centers, encourage them to apply for funding to serve people experiencing homelessness and/or to open new sites in strategic locations
- CMS: Apply to participate in CMS Innovation Accelerator Program Technical Assistance
- It is important to create improved discharge planning protocols for organizations such as hospitals, jails/prisons, and psychiatric institutions. The discharge planning process should begin at the point of admission and include a housing element/connect to the local CoC
- Educate housing/homeless assistance providers about how Medicaid can fund supportive services
- What supportive services are or could be covered by a state’s Medicaid plan?
- What services do existing Medicaid billers in the area provide or could provide?
Eccovia Solutions is proud to play a key role in our clients’ success in improving housing and health outcomes for homeless individuals in their communities. With our deep expertise in HMIS and coordinating care for vulnerable populations, we are a knowledgeable technology partner who can do the heavy lifting so you focus on your clients.