How a Primary Care-Based Housing Instability Program Cut Outpatient Utilization

A community health worker-led program to address housing instability was effective at reducing primary care and outpatient care overutilization, proving that addressing the social determinant of health can pay off in clinical quality outcomes, according to a new study in Health Affairs.

The report, completed by researchers from Brigham and Women’s Hospital in Boston, outlined the success of a program that connected housing unstable patients with community health workers to address key patient needs. CHW job functions ranged from helping individuals fill out housing applications to helping them obtain reasonable housing accommodations.

Still, the program showed a glaring blind spot in the nation’s overall approach to housing: there’s simply a dearth of affordable housing options, which hamstrings healthcare’s efforts to address housing instability.

More and more research has emerged demonstrating the link between housing and health, the researchers said. Eviction has been tied to all-cause mortality, and the housing affordability crisis is more deeply affecting populations of color than their counterparts.

The medical industry’s renewed attention to SDOH, like housing, has spurred some progress on the issue. More SDOH screenings have helped uncover which patients may be at risk for poor outcomes due to their housing instability, and some organizations have even begun setting up programming to address housing as an SDOH.

But most of those interventions look specifically at unhoused people, as opposed to individuals who are housed but face housing instability, defined as having multiple moves in 12 months or being worried about losing housing within two months. Housing instability can also refer to unsafe housing, like pest infestations or the presence of lead.

The program detailed in this study was tailored specifically for the 20 percent of patients visiting Brigham’s 15 participating primary care clinics who screened positive for housing instability.

Led by a team of housing advocates, community health workers, community resource specialists, and medical-legal partners, the program worked to help support those experiencing unstable housing by helping them find shelter or manage a landlord/property management issue.

In total, the program supported more than 1,000 patients, most of whom were insured by Medicaid, female, non-White, and non-English-speaking. Patients supported by the program also had a higher rate of chronic conditions and higher emergency department and inpatient utilization.

Brigham’s program addressed a range of issues, with 8.6 percent of patients experiencing homelessness, 25 percent being at risk for eviction, 35 percent having unsafe or unhealthy housing, and 30.7 percent being safely housed without eviction risk but desired change.

To that end, the services housing advocates provided were manifold: 23.7 percent of patients got housing search and application assistance, 22.7 percent received support for reasonable accommodation requests, 14.2 percent received housing education and empowerment, and 8.3 percent received assistance with funding applications, like Rental Assistance for Families in Transition.

Overall, the program was effective, particularly in helping patients’ housing situations. Although 50 percent of the housing outcomes were categorized as “unclear,” 14 percent of participants were able to obtain reasonable accommodation, 8 percent maintained stable housing, and 7.8 percent accepted a housing offer.

What’s more, the program helped patients avoid healthcare overutilization. Patients enrolled in the program between October 2018 and March 2021 had 2.5 fewer primary care visits and 3.6 fewer outpatient visits compared to those who received usual care. These outpatient visits included social work, behavioral health, psychiatry, and urgent care visits.

A reduction in outpatient utilization indicates that patients were better equipped to manage their health and well-being outside of the clinic.

However, the data did not reveal a link between program participation and ED and inpatient care utilization, nor a link with chronic disease control.

These null results did not surprise the researchers. In fact, they noted that annual reporting of program results is not always reflective of the larger impact a program can have. However, most SDOH programs need to regularly report their results to continue getting program funding, the researchers acknowledged.

Patients also reported better mental and physical health, as well as a better patient-provider relationship. Patients specifically cited the compassionate care that housing advocates, who worked akin to community health workers, provided to them.

“Patient voice makes visible hidden benefits of policies and interventions,” the researchers said. “Interview participants did not expound on health care use or chronic disease control. Instead, they effusively recounted the support and compassion they received from housing advocates while navigating intense housing stressors and the indignities of fractured systems—even among patients whose housing remained unchanged.”

The researchers suggested alternative key performance indicators for housing programs, such as social-return-on-investment.

Moving forward, examining other housing programs could help enhance SDOH interventions. However, the researchers pointed out a problem that is outside the scope of the healthcare industry: the overall lack of affordable housing options. This is evidenced by the nearly half of participants for whom there were no documented housing resolutions. The researchers said this indicated a lack of viable solutions to their problems.

There is certainly a place for advocacy in addressing a need for affordable housing, the team noted, but it will also be fruitful for organizations to consider how their processes and systems aggravate the housing instability problem.

“They should also consider redressing their own historical role in exacerbating housing crises through pursuing medical debt collection, paying wages too low to enable workers to afford median rents, and expanding as tax-exempt organizations—thus increasing land values and potentially disrupting real estate and subsidized housing—without ensuring proportionate community investment,” the researchers concluded.