UnitedHealth is making news by funding housing and services for people experiencing homelessness. The company is betting that housing stability will also lead to a reduction in high-cost medical services, such as hospital stays and emergency department visits.
It’s not a bad bet. A growing body of evidence demonstrates the positive impact of housing and services for people who have experienced a cycle of poor health and homelessness.
One 2012 randomized controlled trial found that people in supportive housing spent 3 fewer days in hospitals, had 1 fewer emergency room visit, spent 8 fewer days in residential substance abuse treatment, and spent 10 fewer days in nursing homes each year when compared with a similar group of people not in supportive housing.
The study also found that people in supportive housing had four more outpatient visits each year, an indicator that the program worked by connecting people to better outpatient care to manage ongoing health concerns and helped them avoid some of the health crises that require emergency care. Shifting from emergency services to primary and preventative care can also result in better outcomes for patients.
But as UnitedHealth’s senior vice president for clinical redesign points out, this is still largely uncharted territory. “I don’t think we’ve figured any of this out,” he said. And where UnitedHealth’s bet may be risky is in the details of how supportive housing works, and for whom.
Bloomberg reported that UnitedHealth provides housing and services with the goal that people will “graduate within a year to paying their own rent.” But people with long-term experiences of homelessness have serious unmet health needs.
The unique challenges of chronic homelessness
Nearly one-third of all people experiencing chronic homelessness are living with a serious mental illness such as depression or schizophrenia, according to the Office of National Drug Control Policy. Among people experiencing homelessness in Boston from 2003 to 2008, drug overdose accounted for one-third of deaths among adults younger than 45.
Addressing these needs requires intensive, high-quality clinical services and often more than one year of housing assistance.
In a study that tracked nearly 1,000 people in a Philadelphia permanent housing program between 2001 and 2004, the average length of stay in the program was more than three and a half years. Among the 41 percent of people who left the program, two-thirds left for what the study categorized as nonpositive reasons, such as needing more intensive residential support or returning to homelessness.
The study found that although the program substantially reduced inpatient service use for both those who stayed in the program and those who left for positive reasons, the trend was reversed for those who left for nonpositive reasons. The percentage of people with an inpatient service claim who left for nonpositive reasons increased from 19 percent before permanent housing entry to 28 percent, a statistically significant increase.
There is a strong case to be made that health care plans should be funding housing for members who would otherwise continue to cycle through health crises and homelessness. Housing can improve lives and save health care dollars, or at least put those dollars to better use.
Four ways UnitedHealth and others can get the best return on their investments:
1. Look closely at who is eligible for the program.
UnitedHealth should make sure housing and services match what people need and is grounded in program models with evidence of success. Continuous quality improvement processes can support high-quality implementation.
2. Use data to monitor and evaluate outcomes.
Although health care can bring a sophisticated data lens to implementation, it will be important to understand people’s experiences in housing, particularly during the pilot phase. Qualitative data can help shed light on tricky questions like why people may be reluctant to move into housing and why they may continue to visit the emergency department while in housing.
3. Move from tracking use of health services to measuring real changes in health.
Receiving treatment for a chronic health issue is better than not addressing the issue at all. Sometimes when service use goes up, a person’s health may be improving. But the literature is weak when it comes to measuring things like burden of illness and quality of life.
4. Advocate for more federal dollars.
Pilots like these can be important to show success and document return on investment, but ultimately, the only player in town that can meet our country’s housing needs is the federal government.
Companies like UnitedHealth have a lot of political capital they could use to push for more housing resources, and that is the only way to reach a scale that could start to fix the nation’s health care crisis.