Primary Care Housing Program Reduced Outpatient Visits and Improved Patient-Reported Health Benefits

A paper published in Health Affairs, Primary Care-Based Housing Program Reduced Outpatient Visits; Patients Reported Mental and Physical Health Benefits,” explores the outcomes of a healthcare-based housing program in Boston, MA, that provided support to patients currently experiencing homelessness, as well as upstream interventions to households at risk of housing instability and homelessness. The authors found that patients enrolled in the program had 2.5 fewer primary care visits and 3.6 fewer outpatient (e.g., social work, behavioral health, psychiatry, urgent care) visits per year on average, relative to comparable patients not enrolled in the program. Additionally, patients in the program indicated that their interactions with housing advocates helped to improve their mental health and their perceptions of the primary care site at which they received care, regardless of the patients’ housing outcome at the end of the study period. This research adds to a growing body of literature focused on the intersection of safe, affordable housing and health and highlights the potential of cross-sector partnerships for addressing health inequities and establishing trust between marginalized communities and healthcare institutions.

The housing program in question was established in 2018 by Brigham Health, a Boston-based academic medical center, after it was observed that one in five patients seen in its primary care clinics were experiencing homelessness or housing instability. In response, a social care team consisting of housing advocates, community resource specialists, community health workers, and a medical-legal partner was formed to address health-related social needs among patients receiving primary care services at any of the medical center’s 15 primary care locations. The housing advocates helped patients experiencing homelessness or unstable housing situations complete housing applications, negotiate with landlords or property management, submit reasonable accommodation requests, and arrange for shelter placements.

The authors used a mixed methods approach to evaluate the impact of the Brigham Health housing program over the course of three years (October 2018 to March 2021), during which time the social care team supported more than 1,000 patients. Relying on analyses of electronic medical records and housing outcomes, as well as qualitative data from semi-structured interviews with a selection of primary care patients, the authors aimed to answer three key questions:

  1. Was housing program participation associated with differences in healthcare use or chronic disease management?
  2. What types of housing problems do patients have? What housing services and outcomes were the housing advocates able to provide?
  3. What were patients’ views on the experience and value of participating in the housing program? In the same vein, did patients have any perceived effects on their health and wellbeing to report?

The researchers found a significant reduction in the utilization of primary care and outpatient services among housing program participants when compared to patients not participating in the program – specifically, an 81% reduction in social work visits and a 60% reduction in behavioral health, psychiatry, and urgent care visits. However, they did not find a statistically significant difference between program participants and non-participants in other measures of healthcare use and chronic disease management, such as emergency department use, inpatient care use, and diabetes or depression control. These findings demonstrate how housing interventions can help to reduce downstream healthcare costs. Prior research has shown that experiencing housing-related stressors such as homelessness, housing cost burden, being at risk for eviction, or being exposed to unhealthy housing can lead to overutilization of medical appointments and, in turn, higher healthcare costs. These costs can further burden households experiencing housing instability or homelessness.

To answer the second research question, the researchers reviewed 286 patient medical charts. Among the 257 patients whose charts included documentation on patients’ participation in the housing program, they found that 8.6% were experiencing homelessness, 25.3% were at risk for eviction, 35.4% had unsafe or unhealthy housing conditions, and 30.7% were safely housed without eviction risk but desired change. Post-intervention outcomes for some patients were successful, with 14.4% of patients obtaining reasonable accommodations, 8.2% maintaining access to stable housing, and 7.8% accepting a new housing offer. Housing outcomes were unclear for just over half of the patients reviewed, many of whom were still on housing waitlists at the end of the evaluation period.

To address the third question, the authors analyzed qualitative data from interviews with housing program participants, from which four key themes emerged. First, the majority of patients described experiencing compounding housing stressors that collectively resulted in a need to change their housing situation. Named stressors included fearing for one’s safety, needing more space, experiencing an unexpected and unwanted move, and experiencing unhealthy housing conditions. Second, many patients who gained access to new housing reported health improvements both in their physical and mental health. Patients attributed improvements to physical health to increased access to exercise, alleviation of exposure to allergens, and elimination of mobility obstacles after moving to new housing. Third, regardless of their housing outcomes at the end of the study period, almost all patients interviewed reported improved mental health and valued the compassion, empathy, and respect they received from the housing advocates. Lastly, some participants who were able to gain new housing opportunities continued to experience suboptimal conditions in their new environment. About a third of patients who changed their housing during the evaluation period reported that they would need to move again due to serious issues such as inaccessibility, racial discrimination, rising rents, landlord disputes, and poor maintenance. These experiences highlight the vital need for greater funding for the preservation and rehabilitation of existing affordable housing, as well as the enactment of stronger tenant protections at the state and local level.

The authors recommend that healthcare systems consider advocating for policies that support the development and preservation of affordable housing units and pursue opportunities themselves to create dignified affordable housing solutions, as some healthcare systems have already done. For example, Kaiser Permanente has shown a commitment to addressing housing affordability by supporting affordable housing preservation and development through its Thriving Communities Fund. The authors also advise healthcare systems to be mindful of the role they play in perpetuating housing instability through medical debt collection and choosing not to pay hospital service workers a living wage with which they can afford rent.

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