Thursday, March 26, 2015

Housing the chronically homeless is Right Care in action

I've been a fan of Dr. Mitchell Katz, director of the safety net health care system in Los Angeles County, California, since reading his 2013 editorial arguing we should stop offering prostate-specific antigen screening because the substantial resources devoted to testing and subsequent diagnostic workups could be better utilized to provide high-value care. I had the chance to hear Dr. Katz speak in person a few weeks ago at the Lown Institute's Road to Right Care conference on another topic that I've written about before: providing supportive housing to chronically homeless persons.

As profiled in a feature article in the March/April issue of Mother Jones, the "Housing First" approach recognizes that many, if not most people who are chronically homeless struggle with mental illness or addiction. Both of these health problems, if inadequately treated, are likely to land patients in two of the most expensive temporary housing situations imaginable: hospital emergency rooms or prisons. Provided with a place to live and convenient access to counseling and health services, however, these individuals often thrive, at a fraction of the costs they would have incurred otherwise.

Housing First has been as successful in Salt Lake City as in New York City, and is now improving population health in Los Angeles. As Dr. Katz put it simply in his presentation, "There are a lot of chronic health problems that we can't cure. Chronic homelessness isn't one of them. Provide supportive housing. Problem cured."

An obstacle to implementing this strategy is resistance from local residents to the prospect of living next door to an apartment complex full of previously homeless people. And sometimes a suitable building is either too expensive to rent or just unavailable. One alternative approach is scattered-site housing, where clients are dispersed into housing units in multiple locations across a city. Until recently, though, we didn't know how well this would work. Earlier this month, JAMA published a randomized trial of scattered-site housing and case management services in four Canadian cities that found improved housing stability compared to usual care 24 months into the program. As the evidence accumulates, it is time to advocate for taking down bureaucratic barriers, Dr. Katz wrote in an accompanying editorial:

An important step toward substantially reducing chronic homelessness would be reimbursement for housing as a medical service for persons who are chronically ill and covered by Medicaid, Medicare, and private insurance. ... Clinicians who provide care for homeless persons are aware that they can order a variety of reimbursable tests and treatments for them, except the one intervention that most likely would make all the difference - supportive housing.

Created by the Affordable Care Act and chaired by the Surgeon General, the National Prevention Council is intended to coordinate federal prevention, health promotion, and public health activities across 20 different federal agencies, including several that are not traditionally thought of as being health-related but have significant influences on health. A strong recommendation from the Prevention Council to Congress supporting the addition of housing as a preventive service that saves money and improves health outcomes might actually be something both political parties could get behind.