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To Reduce Chronic Homelessness, A Chicago Hospital Is Treating It As A Medical Condition

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This story is part of a series looking at places around the U.S. that are successfully reducing homelessness. Check out all of our stories.

The University of Illinois Hospital is one of a few hospitals in the Chicago area that have started providing permanent housing for homeless patients that repeatedly show up in emergency rooms.

The program, called Better Health Through Housing, in partnership with the Center for Housing and Health, treats chronic homelessness as a health issue. Finding people permanent supportive housing also reduces health care costs, says Stephen Brown, director of preventive emergency medicine at the University of Illinois Hospital.

“So if someone is living unsheltered under a bridge, and they have no other options because they might have been kicked out of crisis shelters, they’re going to come to our emergency department and seek care,” he says. “So we’ve now got some pretty compelling data that the solution may be cheaper than the problem.”

While many people who are homeless come to the hospital just to seek shelter, many others come to the ER for legitimate health issues, Brown says.

Putting them in permanent housing also helps improve their overall health, he says: They aren’t out on the street where they’re more prone to injury, violence and frostbite.

“Being homeless is hard on the body … and if you have a chronic medical condition, it’s only going to exacerbate it,” he says. “We also found some individuals that were just coming for what we call ‘secondary gain,’ and their health care costs plummeted because they had no reason to seek out shelter in emergency departments any longer.”

Interview Highlights

On how the program works

“We partnered with the Center for Housing and Health, it’s a subsidiary of the AIDS Foundation. They were looking to replicate some of the outcomes from a randomized-control trial here that was done in the early 2000s that demonstrated the efficacy of what we call ‘housing first’ — putting somebody into housing immediately without any preconditions. And so we’re a state institution with a health equity mission, and it really gravitated with us [as] really something that we wanted to participate in, and so we agreed to be their first hospital partner. We identified chronically homeless individuals — those that are homeless continuously for over a year or who have had four episodes in the previous three years — and then transition them into permanent supportive housing. And then we tracked their mortality, their morbidity and their cost and utilization.”

On the role of hospitals in finding housing for homeless people

“So when we started doing this, we were kind of in the blind and found our way around this. I think we didn’t really have a strong justification to doing this other than it was part of our health equity mission, and it was the right thing to do. But kind of backing into it after having gone through this experience I think we’ve got a lot of compelling data that essentially says that housing is health. That once you put someone into stable housing with a little bit of support, or more support depending on the severity of their mental illness or substance abuse, they tend to do well. And that means that they stop coming to emergency departments. So they often come for nonmedical reasons. We call it secondary gain. So if someone is living unsheltered under a bridge, and they have no other options because they might have been kicked out of crisis shelters, they’re going to come to our emergency department and seek care. So we’ve now got some pretty compelling data that the solution may be cheaper than the problem.”

On the cost of finding housing for people who are homeless

“We pay $1,000 per member per month, a maximum of $12,000 a year. That’s put together with a number of other subsidies that the Center for Housing and Health has with [the Department of Housing and Urban Development] and other grantors. If you were to look at the total cost of housing and support for an individual that would be in a housing-first model, it’s about fully loaded about $25,000 a year. Now if you contrast that with just the health care costs and only my health care costs — I’m not able to look at Medicaid claims data — we had patients that had health care costs somewhere between two-and-a-half to 160 times our average patient cost. One gentleman who was deceased before I ever met him had a reimbursable cost from the state of $938,000. We often joke it’s probably cheaper to put them up in a hotel on North Michigan [Avenue] at $625 a night. An ER visit’s about $1,200.”

On how the program is funded

“We did this originally through a gifting account through some philanthropic dollars in our first fiscal year. The hospital’s now committed through fiscal year 2023 through our operating budget. I must say though what we’re doing is not sustainable because we’re not being paid for it. But there’s a much larger effort going on in Chicago through what we call the flexible housing pool that’s going to make this sustainable. And we’re attracting a number of insurance companies that are looking at some of the data … and we’re making a really compelling economic argument to insurance companies that it’s worth the investment in housing. So there are several managed-care organizations that manage Medicaid patients here that are very interested in some of the data that we have.”

On who pays the hospital bills 

“Ultimately the state because we’re a Medicaid-expansion state. If this were a non-Medicaid-expansion state, it would be in the best economic interest of the hospital to pay for the housing of these individuals because they’re losing money on these individuals. In the state of Illinois, about 85 percent of the homeless have some form of insurance. And we don’t have the results yet, we’ll have it in a month, but we’re running it on this 1,200 patients that we know to be homeless. We’re doing a profit and loss statement to the hospital, which I think it would be very interesting for other hospitals to look at once we’re completed with the study.”

On how to deal with homelessness in general 

“When you start with homelessness, the thing about it is it’s uber complex. It’s just not about health care. These individuals have had significant engagement with the criminal justice system. They get picked up by EMS for chronic inebriation, or they’re in psychiatric crisis, they’re brought to our emergency department. Police and fire bring them up. And whenever I talk to anybody in all these different public sectors, everybody says the same things, ‘Your people are my people.’ The intersectionality of these people [is] extraordinary, and so there are extraordinary conversations going on across the city with real estate developers, banking and finance that want to be able to give us the sustainable financing we need to create permanent supportive housing for these individuals.

“We’re talking with people in the jail. It turns out the lack of housing is a huge source of the recidivism rate here in the state of Illinois, which is about 44 percent after two years. So it’s an uber complex thing and [if you] just keep peeling back the onion, you find more and more. The good news is that we all kind of went from working in our silos and being very narrow in our thinking, now to it’s much more expansive and people are much willing to have more collaborative conversations, and I think we’re going to see some great outcomes here this year with the launch of the flexible housing pool. The other thing I should mention about the pool is once fully funded — and that’s about $12 million and if there’s any corporations out there that would like to help us, give me a call — but once fully funded, it actually builds capacity. So that will create 750 new affordable housing units here in the city of Chicago. So every hospital that contributes to the pool is not only serving their narrow interests, but also the greater good. This idea of collective impact is really resonating here in Chicago.”

Julia Corcoran produced and edited this interview for broadcast with Todd Mundt. Samantha Raphelson adapted it for the web. 

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