Housing and integrated social services improved the health of children and adults in medically complex families, a new study found.
Priority placement in affordable housing coupled with case management, financial and legal services for families that combat chronic diseases and housing instability significantly improved both physical and mental health compared with families that received the standard resource guides and hospital-based social work. The holistic model reduced the share of children with fair or poor health by 32 percentage points over six months and average scores for anxiety and depression among adult family members declined by 1.38 and 1.04 points, respectively, according to a new study from a group of Boston researchers published in Health Affairs.
The findings support existing research linking housing and health outcomes, a dynamic that will be heavily tested as millions lose their job and face financial insecurity as a result of the COVID-19 pandemic, said Allison Bovell-Ammon, lead author of the study and director of policy strategy at Children's HealthWatch at Boston Medical Center.
"The COVID-19 crisis will have very immediate effects on homelessness and housing stability," she said. "There will be a ripple effect."
The healthcare industry is in the early stages of helping families and individuals cope with everyday issues outside of the hospital. There are more programs that help people tackle housing, nutrition, transportation, legal and financial issues, but they are often narrowly targeted and limited in reach. Also, while studies show health outcomes improve with wraparound services, capacity and reimbursement constraints limit efforts.
Bovell-Ammon and her peers designed a pilot randomized controlled trial called Housing Prescriptions as Health Care in conjunction with human services agencies, a Medicaid managed care payer, legal experts and a public housing authority. Those families were either homeless in the previous year, moved multiple times, were late on rent or spent more than half of the family income on rent. They also had a child who had a chronic condition requiring speciality care or had a family member who went to the emergency department multiple times a year.
They tracked 67 families over more than two years, which the researches conceded was a small sample size, finding that a unique approach was required for each family, among other conclusions. While a family facing eviction required a housing solution to free up bandwidth for anything else, there wasn't a set of steps on what to address next, Bovell-Ammon said.
"You need to be nimble in the intervention and meet the families where they were," she said, adding that healthcare providers need a mix of internal expertise that can navigate healthcare issues as well as partners in the community who can guide them through the broader social service network.
"There is increasing interest in healthcare systems thinking about how to address those needs, and housing mobility programs are important options," said Dr. Craig Pollack, an associate professor of medicine at the Johns Hopkins University School of Medicine, who found that children were hospitalized less when their families received housing vouchers to move to better neighborhoods. Stable housing improves kids' health, academics and earning potential, he and his peers found.
But housing alone won't yield the best results, said Lesley Cottrell, professor of pediatrics at West Virginia University and director of its center of excellence in disabilities, emphasizing that it's important to integrate transportation, financial, nutrition and other services with housing initiatives.
"We will see a difference in all healthcare outcomes," she said. "How involved patients will be in their own medical care will improve because they can attend to these items. I don't think these services will individually resolve the problem, but as you layer these services on top of one another, each one will bump up their health."
One of the biggest issues was childcare, which there isn't enough of and can jeopardize employment, Bovell-Ammon said. Another was immigration status, which could limit what programs families could access.
The Medicaid program, among other state and federal programs like food stamps, can be an untapped resource, she said. The Medicaid Section 1115 waivers, which enable states to test ways to deliver or pay for health services, have freed up funding for nonmedical services like housing. While those waivers are promising, they will be unable to effectively meet the needs of patients and families without substantial increases in public financing for affordable housing, researchers noted.
Also, only a quarter of low-income households that are eligible for rental assistance receive a subsidy, researchers said, advocating for more government resources to build more affordable homes, increase rental assistance and provide emergency assistance for families and individuals.
The Residential Assistance for Families in Transition program in Massachusetts helps families cover their rent, noted Bovell-Ammon, adding that they are working on setting up emergency funding through that program.
Even before the crisis, families that were eligible for housing subsidies like one that adjusts rent to the hours a person works did not receive them. More programs like that are needed to prevent homelessness, she said.
"While there are foreclosure moratoriums in place for people with certain types of housing, those don't protect everyone," Bovell-Ammon said. "That also doesn't mean that your rent won't continue to accrue."