Ken Perez: How homelessness and healthcare are inextricably linked

Homelessness is a worsening problem for the United States, and in multiple ways, it is a healthcare issue. Many of our nation’s failed efforts to solve this problem, outlined below, do not fully acknowledge this reality. But a promising new not-for-profit initiative, Built for Zero, may provide a truly viable solution using a data-driven approach that includes participation by healthcare providers.

The connection between homelessness and healthcare

Homelessness is a healthcare issue for a number of reasons. It is unquestionably a major social determinant of health (SDoH). Australian researchers Amanda Stafford and Lisa Wood conclude: “Homelessness is associated with enormous health inequalities, including shorter life expectancy, higher morbidity and greater usage of acute hospital services. Viewed through the lens of social determinants, homelessness is a key driver of poor health, but homelessness itself results from accumulated adverse social and economic conditions.”^a

How bad is the health of homeless people? Sachin Jain, president and CEO at SCAN Group and SCAN Health Plan, observes: “Diabetes. Hypertension. Heart Disease. Hepatitis C. HIV. These diseases are rampant among the homeless population. In fact, if the connection between homelessness and poor health weren’t clear enough, then consider that researchers have found that being homeless takes 20 years off a person’s lifespan.”^b

Not surprisingly, the homeless, and especially the chronically homeless, are frequent users of emergency departments (EDs). A survey by the National Center for Health Statistics found that the average homeless person visits the ED almost five times as often as the average non-homeless person.^c In fact, almost one-third of ED visits are made by the chronically homeless.^d This trend obviously contributes to overcrowding and added costs, especially relative to a visit to a primary care physician, but even more sobering is the fact that most of the care homeless people receive in ED does not adequately address their health needs, which Jain notes are often both behavioral and physical in nature.

The fallacies of simplistic solutions

Given the enormity and complexity of the homelessness problem, there is good reason to be leery of the often-touted broad-brush solutions to homelessness, which include the following.

Throwing more money at the problem.  Clearly, more money will be required to ameliorate homelessness. But efforts that amount to simply throwing more money at the problem have been proven empirically to be ineffective. For example, California spent $17.5 billion from 2018 to 2022 to combat homelessness, but the state’s homeless population actually grew — there are more than 170,000 people without housing in California currently, and the Golden State is adding more homeless people annually than any other state.^e As is often the case, when billions of dollars of public funds are committed to solve a problem, the number of Band-Aid-like programs proliferates, resulting in fragmentation.

Institutionalizing homeless people who have mental illness. California Gov. Gavin Newsom, former President Donald Trump and Florida Gov. Ron DeSantis have all touted institutionalization as a way to deal with homelessness.^f But it would clearly be only a partial solution, addressing the 20% to 30% of the homeless population who are mentally ill, according to numerous studies.

Giving the homeless homes, without any preconditions. This idea was a response to the “treat issues first, offer housing later” approach that characterized how the nation dealt with homelessness after the well-publicized failures of public housing from the 1960s through the 1990s, most famously the squalid conditions, rampant crime and racial segregation in the Cabrini-Green Homes in Chicago, Ill.

The Housing First strategy, introduced in the 1990s, prioritizes giving people housing first and then additional support services. While it has been the guiding principle for homeless programs of the U.S. Department of Housing and Urban Development, its track record has been uneven, with some successes (e.g., Houston) and some relative failures (e.g., San Diego). Sometimes the Housing First approach has been reduced in practice to a housing-only approach, with less focus on additional support services. Housing-only ignores the lessons learned from the nation’s public housing experience. A recent example of a housing-only initiative is the July 17 executive order by Hawaii Gov. Josh Green, who is a physician, in response to the homelessness crisis in his state. The order facilitates the construction of 50,000 new homes in the next three to five years by lowering regulatory barriers to building homes.^g

Because of the high ED usage by people experiencing homelessness, hospitals serve as an upstream place of connection with them. Recognizing that key role of hospitals, California Senate Bill 1152, which was signed into law in 2018 by then-California Gov. Jerry Brown and took effect Jan. 1, 2019, required hospitals to discharge a homeless patient to a safe and appropriate location, and to generate a written plan for coordinating services and referrals with healthcare and social service providers. This solution unfortunately overlooked the problem of the shortage of service providers who could handle the increasing volume of homeless patients who still need aftercare and housing once discharged from the hospital.^h Despite this shortcoming, the law was rightly advocating for a more coordinated and comprehensive approach to homelessness.

Built for Zero

A more effective means of addressing the homelessness issues may be found in the Built for Zero movement, which ambitiously aims to actually solve homelessness, in contrast with the Biden administration’s goal of reducing homelessness by 25% by 2025.ⁱ An initiative of Community Solutions, a New York, N.Y.-based non-profit organization focused on ending homelessness, Built for Zero aims to achieving and sustain “functional zero,” a milestone indicating “that homelessness is measurably rare and brief for a population.”^j

The program is a more advanced movement in the Housing First tradition that includes over 100 communities working to measurably end homelessness. The pillars of the Built for Zero methodology are:

• Creating a shared definition of the desired final outcome: functional zero^k
• Assembling an accountable, community-wide team across not-for-profit groups, healthcare organizations, city and county government, the housing authority and the local Veterans Affairs office
• Using real-time data, which accounts for everyone by name and individual need
• Centering on racial equity issues
• Making targeted, data-informed housing investments

Built for Zero emphasizes a data-driven, coordinated systems approach, including collaboration with the healthcare system. In addition, the numerous communities in the Built for Zero movement constitute a strong peer network, facilitating sharing about pain points and best practices.

To date, 14 communities in the United States have achieved functional zero for at least one population, including 12 that have ended veteran homelessness and five that have solved chronic homelessness. Three of those organizations have solved both veteran and chronic homelessness (Abilene, Texas; Bergen County, New Jersey; and Winnebago and Boone Counties, Illinois).

Critics question the scalability of the model, although Bergen County has a population approaching 1 million, and Bakersfield, California, one of the communities that has ended chronic homelessness, has a population of over 400,000.

Parallels with and opportunities for healthcare

In healthcare, patient-centered care focuses on the patient and the individual’s particular healthcare needs. In like manner, Built for Zero seeks to understand and meet the needs of each individual homeless person, using a data-driven approach. For instance, the Bakersfield-Kern Regional Homeless Collaborative compiled a by-name list of every person experiencing homeless. Then the collaborative worked to find housing and other services for every person on the list one by one through recurring problem-solving meetings.

And like longitudinal care plans, Built for Zero coordinates programs that span prevention, emergency response (including shelters) and perhaps most important, accommodation and supports — a category that includes various forms of more permanent housing and financial stabilization. This is the key to breaking the cycle of chronic, revolving-door homelessness.

In addition to being an active participant and collaborator in community-wide Built for Zero initiatives, healthcare providers can provide outbound care to people without housing, rather than waiting for them to show up at the ED. Street medicine teams, mobile medical clinics and other forms of outreach have proven that they can establish trusting relationships with the homeless and address many of their needs without admitting them to a hospital.

Hard work, but more than worthwhile

A common response among people who are just beginning to hear about Built for Zero’s highly coordinated, person-centered approach is to say, “That’s a lot of work.” They are right.  But the alternative to doing that work with uncoordinated, one-size-fits-all solutions that fail to address the various needs of the individual — has failed for decades, leaving our society with a worsening homelessness crisis.

Footnotes

a. Stafford, A., and Wood, L., “Tackling health disparities for people who are homeless? Start with social determinants,” International Journal of Environmental Research and Public Health, December 2017.
b. Jain, S.H., “Homelessness is a healthcare issue. Why don’t we treat it as one?” Forbes, April 17, 2021.
c. U.S. Department of Health and Human Services/Centers for Disease Control and Prevention, “Rate of emergency department (ED) Visits, by homeless status and geographic region — National Hospital Ambulatory Medical Care Survey, United States, 2015–2018,” The Morbidity and Mortality Weekly Report, Dec. 18, 2020.
d. Green Doors, “The cost of homelessness facts,” accessed Aug. 23, 2023.
e. Watt, N., “California has spent billions to fight homelessness. The problem has gotten worse,” CNN, July 11, 2023.
f. Morian, D., “Newsom takes another swing at getting mentally ill homeless off the streets,” Capitol Weekly, March 19, 2023; and Payne, D., “2024 GOP candidates’ health policy check-up,” Politico Pulse, Aug. 8, 2023.
g. Yerton, S., “Hawaii gov takes dramatic action to solve housing crisis. But is he going too far?” Honolulu Civil Beat, July 17, 2023.
h. Bruno, K., and Hunn, M., “new law does little to guarantee support once homeless are discharged from hospital,” California Health Report, Oct. 3, 2018.
i. U.S. Department of Health and Human Services, “After halting rapid rise in homelessness, Biden-Harris Administration announces plan to reduce homelessness by 25% by 2025,” Dec. 19, 2022.
j. Community Solutions, “Built for Zero,” accessed Aug. 23, 2023.
k. Functional zero, according to Built for Zero, is a dynamic milestone that indicates a community has made homelessness in its population rare overall and brief when it occurs.

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The extent of the homelessness problem

A point-in-time estimate of homelessness by the U.S. Department of Housing and Urban Development found that in 2022, on a single night versus throughout the year, about 582,500 Americans were homeless nationwide.^a Homelessness —  defined as “lacking a regular nighttime residence or having a primary nighttime residence that is a temporary shelter or other place not designed for sleeping”— has been a longstanding societal problem, with the number of people experiencing homelessness ranging from 550,000 to 650,000 over the past dozen years.^b

Moreover, during the past 15 years, the percentage of the homeless population that is unsheltered has hovered between 30% and 40%.^c

It is often said that every big city in the United States is dealing with homelessness, and indeed, a simple Google news search for “homelessness crisis,” conducted during one week in August, returned 11 U.S. cities, including (diversely) Honolulu, Hawaii; Anchorage, Alaska; Portland, Oregon; Los Angeles, California; Denver, Colorado; Tulsa, Oklahoma; and New York, New York.  But search results also included Western New York and the Flathead Valley in Montana — areas with the so-called “hidden homeless” who live in rural areas.

Chronic homelessness versus short-term homelessness is a key distinction. The former is used to “describe people who have experienced homelessness for at least a year — or repeatedly — while struggling with a disabling condition such as a serious mental illness, substance use disorder, or physical disability.”^d

Footnotes

a. de Sousa, T., et al., The 2022 Annual Homelessness Assessment Report (AHAR) Report to Congress, The U.S. Department of Housing and Urban Development, December 2022.
b. Congress.gov, “H.R.558 – 100th Congress (1987-1988): Stewart B. McKinney Homeless Assistance Act,” July 22, 1987; The New York Times, “582,462 and Counting,” Feb. 3, 2023.
c. USA Facts, “How many homeless people are in the US? What does the data miss?” March 16, 2023.
d. National Alliance to End Homelessness, “Chronically Homeless,” Updated April 2023.