Steve Brown is a nationally recognized expert on housing and health. He is the Director of Preventive Emergency Medicine at the University of Illinois Hospital in Chicago, and the Director of Better Health Through Housing. Nicole Blum, a 3rd year medical student at the University of Illinois Chicago sat down with him to discuss the impacts of housing on healthcare.  

How did you become interested in homelessness and health?

I had come from a Fortune 500 company and transitioned to get my Masters in Social Work really with the intention of becoming a therapist, not to be in health care. I ended up in the ER, and I was just very struck with how health care at the time seemed to be willfully ignoring all of these things that were contributing to poor outcomes. At the same time, there was this emerging recognition of social determinants of health. Again, this is in 2005, and it’s on everyone’s lips now, but at the time [social determinants of health] was not anything that anybody really paid any attention to. I came here in 2011 to start preventative emergency medicine, and out of that, it started as emerging awareness that mental illness, substance use, and homelessness drove a lot of ER utilization. We didn’t have very good data about it, but I had run a program here that was designed to look at health care super-utilizers specifically that came in through the ER. We began to notice that, of those super-utilizers, many were homeless. Then, in 2015, I was asked to run the Better Health Through Housing program because of my work as a social worker doing preventative emergency medicine. It was rather unique in the way it was constructed because it made it very easy for hospitals to refer homeless individuals into permanent supportive housing. I would say that I’ve always been interested in [homelessness] as a social determinant that contributes to ER utilization, but in 2015 that’s when it really started to take off. I see my role as expanding advocacy for hospitals to recognize it for what it is. It really is a dangerous health condition.

Can you tell me more about Better Health Through Housing (BHH) and what it was like to start it?

So the thing about Better Health Through Housing was it really took us in health care unlearning a lot of things and learning new ways to think about how you partner with people and with agencies in the community. There were just some really quick lessons learned. We didn’t think there was much homelessness. But when we began to really dig down into it, and I started being able to mine the electronic medical record, we went from having a basic list of 48 individuals to over 5,000 now. Currently, we think we have about 1,500 people coming through this system every year. We had this huge misconception about homelessness. There are lots of people that have untreated mental illness that won’t go to crisis shelters because they’ve been banned. The other thing we had to unlearn as a hospital was that this wasn’t a discharge, this was a transition. We’re so focused on the urgency of a discharge in the moment, but we had to recognize that many of these individuals could often take a week to a month before they would accept housing from us. We had to allow our housing partners to change some of the terms of the contract midstream. Those were some of the early lessons we had and how we had to adapt.

What have been the biggest successes from this project?

I think it’s drawn attention to redefining homelessness as a dangerous health condition. It has challenged other hospitals to think about what it means to have a sense of mission. We can think about serving individuals that come through our doors as individuals or we can look broadly at the communities in which we serve. I think it’s beginning to refocus hospitals to think about how you improve the health of the residents embedded in the communities that you serve. It’s a very different mindset to think about population health than to think about just individual care. We’re beginning to see more and more hospitals invest in programs like ours where we’re identifying the chronically homeless individuals and moving them [into housing]. I wouldn’t call it a success yet because I think we have a long way to go, and I’m rather frustrated by the pace of it. I’d like to see more hospitals diving into this too. And so how do we do that? One of the things we’re trying to do here is to create a report card with the state so that we can give every hospital a report card with the number of [homeless] people who have come through their ERs that they don’t know about. Hospitals don’t want to find another problem, but we can demonstrate that this is something that warrants their attention and deserves their attention because of the mortality. It’s a dangerous health situation.

Have you noticed a drastic decrease in the amount of ED utilization with the residents in BHH?

Yes, it plummets. We saw in the first cohort drops of ED utilization like 57%. That’s for two reasons. They’re coming for secondary gain because they have no other options because they’re generally unsheltered, and they’re also very sick as a consequence of being unsheltered. Unsheltered mortality rates are 3.5 times the general homeless [mortality] rate.

Can hospitals save money by investing in housing to prevent health care overutilization?

Everyone thinks that’s going to be the downstream consequence. It’s not saving money—it’s avoiding the loss. [Cost savings] depends on where; it depends on the state. If it’s a Medicaid expansion state, in some cases, the hospitals make money on these individuals because about 85% of the homeless now have some form of insurance. You can avoid a loss [by investing in housing]. We’re trying to get data from some of the other states where hospitals are investing in housing so that we can make a better case.

What are some of the challenges you have encountered with BHH and how have you addressed them?

The biggest challenges have been with the alignment of two siloed systems. We cannot do this alone. Our partnership with the Center for Housing and Health is very unique. They give us access to 4,500 units, and that is a very powerful thing. But, even with that, we only expect 125-150 vacancies a month—sometimes we have to wait a couple of months before we can get people into housing. What we need the people on the other side to do in housing is we need a tiered approach to housing. One size does not fit all. Housing in itself is not a panacea. Our retention rates were lower, around 47%, versus national models using the Housing First Model which was around 80%. One of the reasons for this was that we had individuals with severe mental illness and severe substance use disorders, and they needed greater level of supervision. What we didn’t have on the community-based side was access to Assertive community treatment which is evidence-based. [Assertive community treatment] is a very effective way of keeping people out of the hospital, but it wasn’t accessible to us. The other thing we needed was what we call project-based housing. All of what we had was scattered-site housing. We tried to get project-based housing, but we just couldn’t get people into it. There just wasn’t enough of it. Scattered-site housing puts someone in their own apartment. That leads to some social isolation and not enough interaction with a case manager. Sometimes these people need to be in project-based housing where there is support around them; there’s clinical staff onsite 24/7. These are just a couple of the challenges we have. It just gets infinitely more complex with the more siloes you’re working with. The other challenge is that we’re starting to work with law enforcement and the criminal justice system because [homeless individuals] tend to get picked up a lot and for petty crime.

How has Better Health Through Housing (BHH) changed since its founding?

We just added what we call the flexible housing pool. This is a big upgrade; we’ve added a financing component to it now where essentially everyone contributes to a bucket of money. [Homeless individuals] are infinitely complex, and one of the barriers for getting all the supports and services that people needed were that a lot of the grants were very specific about the populations they served. Often times, there would not be the breadth of services necessary to help somebody remain in the community-based setting. A perfect example of this with Better Health Through Housing was the HUD grant for the chronically homeless. Those are folks that are continually homeless for over a year or who have had four episodes [of homelessness] in the previous three years. And yet, we had many people who were more episodic. With this flexible housing pool, there are no inclusion or exclusion criteria—we can house anybody in that because we’re getting funding from a wide variety of funders.

What are some lessons you’ve learned from this project?
One, [homelessness is] a dangerous health condition with a very high mortality rate. Health care needs to reframe it that way and do everything it can to align systems so that we address it as a condition in and of itself. Two, homeless are invisible in health care. Other hospitals are beginning to document; we’re providing technical assistance to help them do that. When you begin to document it, it has to be addressed. If you don’t document it, it’s another one of those problems that nobody else wants to take on. Three, a portion [of homeless individuals] have a very exorbitant amount of health care cost and utilization. We found elevated costs in about 40% of the homeless we found within a year, anywhere from 1.5-160x more expensive than the average patient. Four, more alignment, more alignment, more alignment. This idea that we can do more if hospitals now focus on the concept of collective impact. We’re shifting from individual care to population health, and the only way we’re going to get there and actually have effects on population health is through collective impact.

Has your perspective on homelessness in general changed since 2015?

It’s broadened the definition, more the granularity. Homelessness tends to be thought as a monolith, not on a spectrum like we do with diseases now. Homelessness exists along a spectrum and we need to have a different approach for each one of those along the spectrum. My current interest is in the unsheltered homeless here. We’re beginning to discover that many ERs are bearing the brunt of a shelter system that does not accommodate people with severe mental illness. There’s lots of opportunity for advocacy in this space. My fear is that if we do not address the affordable housing crisis before it happens in the city of Chicago, we’re going to see more people that have jobs [who are homeless]. I hope we get ahead of the affordable housing crisis before we start seeing that type of homelessness pop up.

What advice do you have for physicians caring for the homeless population?

I think physicians, collectively, have the most power to advocate for Social Emergency Medicine.  As I’ve spoken to several different hospitals, it’s generally a strong physician champion that can track funding or get the c-suite to do this. The executives in a hospital are looking at the bottom line, as they should. [Hospitals] operate on very slim margins so they have to be exquisitely attuned to the business side of it. But that in and of itself is not going to compel hospital leadership. It has to be an ethical concern and a medical concern of physicians to drive advocacy to do more of these types of things.

What are your future plans for BHH?

The next great outcomes will come when public system siloes start communicating with each other. What we’re looking at now is getting the criminal justice system to invest in the flexible housing pool because the recidivism rate for the state’s prison system is 44%, and a lot of that is driven by these social determinants. It’s a complicated subject, but homelessness is a major driver of recidivism both in the jail and in the prison system. We need better data systems to be able to say who are the super-utilizers and what can we do to intervene. For example, I’m on this project where we’ve matched jail and state health data and some homeless data, and we found this cohort of these 18-25 year old males that end up on P3, the mental health tier of the jail, and it appears they’re prodromal individuals that will slide into severe mental illness. We haven’t been able to marry health care, housing, and jail data effectively in ways so that we can identify those individuals and get them into mental health care earlier.

How can people get involved and support the project?
We have the Street Medicine team here for medical students which has been very effective.  Also the idea of advocating with other hospitals to encourage them to invest in the flexible housing pool. [When interacting with homeless individuals], just on a personal level, always make eye contact and ask the person their name. They have been so marginalized that they lack human connection that all of us want. It doesn’t mean you have to give money, but you should at least be polite to individuals on a personal level. Other things, be able to advocate at church and school. What we’re trying to do with the flexible housing pool is allow churches to make an investment for individuals. It would be about $20,000 to house, feed, and clothe somebody for a year.

Are there any other projects you’re currently working on or hope to start working on?

I’m giving a set of recommendations to the mayor on October 28th about diversion strategies for folks that are in psychiatric crises post Laquan McDonald. I’m on the oversight committee monitoring the police department’s offering of Crisis Intervention Team training to all police officers. More than that, we now have to have diversion strategies and steer [homeless individuals] away from interaction with the criminal justice system. [We need more] thinking about longitudinal care coordination from the street all the way through a clinic. Cross-sector data exchange, that’s another big thing we’re working on, being able to pull all of this data together because it exists, it just sits in siloes.

Is there anything else you would like to add or say about your work?

Well, I think it’s just more of a recognition that when we think about health equity and health disparities, we think about those things at the individual level, but we have to think about these things at the structural level. My job is addressing structural violence that has existed forever. As a social worker I saw it, I lived it, I breathed it, I was frustrated with it because so many of these people were not getting what they needed, and it’s a huge problem. The good news is that there’s a lot of will, a lot of attention, and a lot of really smart people in the public sector now trying to figure out how to bring it all together. I’m encouraged by some of the work; I certainly wish it would happen faster. I think we all understand what the significant issues are, now we just need to solve them.