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Homeless individuals and families face unique challenges in accessing a health care system built to serve a housed population.1 As a group, chronically homeless individuals suffer disproportionately high rates of mental illness, substance abuse disorders, and chronic conditions that are exacerbated and in some cases caused by living on the streets. People who are homeless are three to four times more likely to die prematurely than their housed counterparts. Nationally, homeless individuals experience average life expectancy as low as 41 years.2
In many States, Medicaid expansion programs will extend insurance coverage to millions of Americans, many of whom who have long-unmet needs for primary and specialty care. Finding providers who understand the distinct physical, psychological, and social needs of the homeless will be a challenge for many States as they seek to improve the health of this population while controlling spending. High-quality care for people who are homeless offers promise to improve disparities, offset costs elsewhere (e.g., fewer emergency room visits, hospitalizations), and contribute to the reduction of homelessness, the underlying cause and consequence of many of the illnesses affecting this population.
For 30 years, the Colorado Coalition for the Homeless has been working to integrate health care and housing services for the homeless based on the principle that safe housing is required to effectively manage the related mental illnesses, substance abuse disorders, and multiple chronic medical conditions. The Coalition takes a multidisciplinary approach to delivering care that combines patient-centered physical care delivery—medical, dental, vision, and pharmacy—with behavioral health care—mental health care and substance treatment services—and supportive housing.
In 2013, the Coalition provided health care services to more than 13,000 homeless individuals and families. Many of the patients the Coalition treats are afflicted with multiple chronic conditions common to those without housing, such as hypertension, diabetes, and asthma. The nonprofit oversaw the development of 1,600 housing units for homeless individuals and families largely in the Denver metropolitan area. Of those units, a significant portion are developed specifically for men and women in frail health whose recovery is hindered by lack of consistent access to nutritious food, clean water, and a safe place to rest.
The Coalition's integrated delivery model responds to specialized needs unique to homeless individuals and families. The Coalition's integrated supportive housing developments are transformational for the residents served. Participants in the Coalition's programs gain the resources necessary to achieve and maintain long-term recovery, stable housing, employment, and overall self-sufficiency.
Recently, the Coalition opened the Stout Street Health Center and Renaissance Stout Street Lofts in Denver's Curtis Park neighborhood. This is the 18th affordable housing development constructed and operated by the Coalition. The Coalition designed the Health Center from the ground up to be targeted to the needs of people who are or have been homeless. Within the 53,000-square-foot Federally Qualified Health Center, the Coalition operates a unique model of care that fully integrates patient-centered care with an emphasis on providing housing and other social services to address the full spectrum of the determinants of health. These facilities provide essential medical care services for up to 18,000 homeless Coloradans each year and provide supportive housing for 78 formerly homeless households. Residency in the Lofts is targeted toward highly vulnerable families who have ongoing health and mental health needs that can be best addressed through onsite social services.
The Health Center introduces a unique model of integrated health care targeted to the needs of homeless patients. It fully integrates patient-centered, trauma-informed medical and mental health care3, substance treatment services, dental and vision care, social services, and supportive housing to more fully address the spectrum of problems homeless adults and children bring to their medical providers.
The Health Center is made possible by the expansion of Medicaid eligibility in Colorado under the Affordable Care Act. Prior to the Affordable Care Act, only 15 percent of homeless individuals served by the Coalition were eligible for Medicaid. Today, nearly 70 percent of the Coalition's patients have been enrolled in Medicaid. The increased payments through Medicaid helped fund the new facility as well as expanded the number of health care providers to serve the unmet need in the community.
Results from the Coalition's new Health Center will be available at the end of 2015. However, the effectiveness of similar work undertaken by the Coalition shows promise that the new Health Center will see improvements in health outcomes for the people it serves and reductions in the cost of caring for them. The Coalition's efforts, which employed a "Housing First" approach, demonstrated marked improvements in health and substantial cost savings in comparing the health and utilization of participants 2 years prior to entering the program and 2 years after. Participants in the program demonstrated a significant housing stability: during the period studied, 77 percent of participants continued to be housed. The Coalition also found that 50 percent of studied participants showed improvements in their health status: 43 percent showed improvements in their mental health status and 15 percent decreased their substance abuse4
Coupled with these improvements in outcomes was a significant decline in the cost of care for the studied participants. Utilization of health services was found to have uniformly declined, with an average cost savings of $31,545 per participant over 2 years when comparing the 2 years prior to entering the program with the 2 years after.5 Even when considering the cost of each patient's housing and support services, which average $13,400 per person per year, the average cost savings was still $4,745 per person over the 2 years.6 In addition to those direct savings, the project is currently estimated to reduce State and local costs for emergency care, detoxification services, and fire and safety services by up to 29 percent annually based on randomized control trials in other settings.7 The results demonstrated by the Colorado Coalition for the Homeless hold promise that access to high-quality health and health care services can demonstrably improve outcomes for persons who are homeless while reducing treatment costs.
These efforts promote person- and family-centered care, effective communication and care coordination, and make quality care more affordable through the lever of Innovation and Diffusion.
The Colorado Coalition for the Homeless is a 501(c)(3) nonprofit organization that provides housing and integrated health care to individuals and families who are homeless in Colorado. The Coalition operates a Federally Qualified Health Center designated as a Healthcare for the Homeless Program. The Coalition operates more than 40 programs at 18 locations that offer a range of services beyond traditional health care services. To learn about the entire scope of the Coalition's work, please visit www.coloradocoalition.org.
1. Gelberg L, Linn LS. Assessing the physical health of homeless adults. JAMA. 1989; 262:1973–1979.
2. O'Connell, James. (2005, December). Premature Mortality in Homeless Populations: A Review of the Literature. Available at http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/PrematureMortalityFinal.pdf.
3.According to the Substance Abuse and Mental Health Services Administration's (SAMHSA's) concept of a trauma-informed approach, “A program, organization, or system that is trauma-informed: realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; responds by fully integrating knowledge about trauma into policies, procedures, and practices; and seeks to actively resist re-traumatization.” More information is available at: http://www.samhsa.gov/nctic/trauma-interventions.
4. Commonwealth Fund. “Colorado Coalition for the Homeless: A Model of Supportive Housing.” Quality Matters. Available at: http://www.commonwealthfund.org/publications/newsletters/quality-matters/2014/october-november/case-study.
5. Perlman, J. and Parvensky, J. (2006). Cost Benefit Analysis and Program Outcomes Report, Denver Housing First Collaborative. Available at http://www.coloradocoalition.org/!userfiles/Housing/Executive_Summary_DHFC_study.pdf.
6. Commonwealth Fund. "Colorado Coalition for the Homeless: A Model of Supportive Housing." Quality Matters. Available at: http://www.commonwealthfund.org/publications/newsletters/quality-matters/2014/october-november/case-study.
7. Sadowski, L.S. (2009). Effect of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults. JAMA. Available at http://jama.ama-assn.org/content/301/17/1771.full.pdf.