The higher prevalence of chronic diseases among this patient population further elevates their risk of suffering from the virus and experiencing poor outcomes. Indeed, according to a report from the National Health Care for the Homeless Council, clinicians caring for the homeless report that their most pressing challenge is serving patients with complex comorbidities. This relationship is often exacerbated by poor mental health and substance use disorder (SUD) as well as limited access to healthcare, cleaning supplies, and nutritious food.

Long preceding the COVID-19 pandemic, abundant evidence connects housing insecurity with barriers to good health and recovery from treatment. Homeless individuals are less likely to have consistent access to high-quality healthcare and other basic needs, such as food and safety. They are also more likely to suffer from mental illness and SUD, both which may require costly treatment and may be inaccessible due to other reasons such as lack of reliable transportation. According to a recent study, hospitalizations for the homeless are increasing across the country and resulting in higher healthcare costs. The authors point out the need to address barriers to ambulatory care (particularly for behavioral health) to improve health and reduce the need for acute care among the homeless population.

Evidence for the potential of affordable housing initiatives to improve health outcomes also exists. For example, researchers from several Boston-area healthcare institutions implemented a randomized control trial called Housing Prescriptions as Health Care for 78 medically complex families experiencing homelessness or housing insecurity. Compared to the current standard of care (relying primarily on care navigators and social workers), priority placement in affordable housing and provision of multiple social services led to significantly greater improvements in children’s physical health and parents’ mental health among those in the intervention group compared to the control group. A 2016 analysis by the Center for Outcomes Research and Education also found that an affordable housing initiative led to a 20% increase in primary care utilization, an 18% reduction in emergency department visits, a 12% decrease in medical expenditures, and reported improvements in care access and quality.

Many health plans are aware of the impact of housing stability on healthcare utilization and patient outcomes, and they are taking action to address these needs. UnitedHealthcare began investing in affordable housing through national and regional organizations in 2011 and by 2019 had invested more than $400 million to build 4,500 new homes in 80 underserved communities across the country, each including services related to healthcare, job training, and other efforts to support residents in maintaining their health. Affordable housing has also been a key focus for Kaiser Permanente for more than 50 years. Through its Thriving Communities Fund, the integrated health system committed to spend up to $200 million to improve the health of its members by addressing housing stability and homelessness.

Partnerships to address housing insecurity have gained further traction amidst the current pandemic. Molina Healthcare of South Carolina, for example, recently donated $75,000 to community-based organizations (CBOs) to address social needs in homeless populations across the state. While many of these organizations are donating food to the food insecure, donations to New Directions in Myrtle Beach will allow for more housing of homeless communities in an effort to provide clean and safe living spaces that will reduce transmission and increase their resilience. Donations to other organizations seek to address other social needs—such as language skills, personal hygiene, and job security—for this homeless population.

In another part of the country, the Tufts Health Plan Foundation has donated $1 million to support a variety of services, including those that address housing insecurity, across the states in New England that it serves. To maximize efficiency and the sharing of expertise, the services receiving support must engage in cross-sector collaboration. The Foundation is also increasing flexibility to its existing grant recipients to enable them to pursue and strengthen efforts specifically related to COVID-19. While it will be important to evaluate the impact of these initiatives in the future, they ultimately intend to reduce the burden on the healthcare system and help to keep people out of the hospital, avoiding both human suffering and costly healthcare interventions.

In May, a group of multidisciplinary stakeholders, including the Neighborhood Service Organization (NSO), Ascension Michigan, Henry Ford Health System, Detroit Area Agency on Aging, and others, launched a novel initiative in Michigan. Funding from both private and public sources has enabled the NSO to work with these partners to establish its Recuperative Housing Center to care for patients experiencing housing insecurity following their hospital stays. This intervention will delay their return to shelters or to the street by ensuring temporary housing and continued care for up to 50 patients so that they can continue to recover and regain their health. The CEO of NSO has also announced that even though this initiative launched in response to the current pandemic, the partners “aim to continue developing long-term solutions for the healthcare delivery system in the space of housing.”

These efforts highlight the importance of establishing partnerships with CBOs that have strong pre-existing community relationships to address social needs, such as housing insecurity. Foundations and health plans can work with CBOs to better connect with community members suffering from the virus and better understand the diversity of needs during such a global pandemic of infectious disease or a widespread burden of chronic disease. Collaborating with CBOs and building on their existing resources, community buy-in, and trust can enable these stakeholders to work together to best and most efficiently understand the needs in local communities. Addressing those local needs can then mitigate some of the risk factors for COVID-19 faced by those with housing insecurity, thereby reducing transmission and minimizing unnecessary utilization.

Additionally, supporting communities to address social needs in the absence of a crisis of this scale could mitigate or prevent the need for providing such emergency services. Investing in initiatives to improve mental health, reduce addiction, improve access to quality education and job resources, and improve access to affordable housing and healthy food—including robust plans for data collection and evaluation to prove their effectiveness—could help reduce the prevalence of homelessness and the need to address conditions that have led to the high rates of transmission and death resulting from the pandemic.

Avalere works with a variety of stakeholders to evaluate patients’ social needs (such as stable and safe housing) and understand how to design and implement interventions to meet those needs. For example, through the Malnutrition Quality Improvement Initiative, we support hospitals and clinics across the country working to address patients’ barriers to nutrition resources, including patients who are discharged after they have screened positively for food insecurity. We have also begun to work with multi-stakeholder partners to study and test interventions seeking to address transportation insecurity as a barrier to healthcare access. Addressing unmet social needs can help improve patient engagement in healthcare, improve health outcomes, and reduce healthcare utilization and costs. Such needs have become even more visible and widespread amid the COVID-19 pandemic and the onset of a deep recession, necessitating action from partners throughout the healthcare industry to prevent further decline in health and increasing challenges to treat and prevent disease in this increasingly complex social environment.

We look forward to continuing and expanding on this important work with more partners. For more information on how we assist our clients evaluate their opportunities and risks in addressing social determinants of health, please contact John Feore.

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