Better Health Through Housing

January 8, 2018 3:49 PM

A year after a pilot program by The University of Illinois Hospital & Health Sciences System in Chicago to house homeless frequent ER patients to reduce costs, the results are in and “If every hospital in the area agreed to house 10 chronically homeless patients, which would be a relatively modest investment, we could collectively make a huge impact on reducing homelessness, and it would be near cost-neutral to every hospital,”
posted by The Whelk (14 comments total)

This is a really great, fascinating idea and I bet/hope SF General and Highland could try this...

That said, what does this mean: Of the 26 initial patients, eight left the program for various reasons, two left because they could not live independently, one entered hospice, and four have died, according to the hospital.

This program has a less than 50% retention rate. What the Hell Are Various Reasons. What happened to the four who died-- did they also enter hospice before they went. Is the hospital actually going to screen out those who are "not capable of living independently," because I feel like that's a really terrible idea. I need so much more information about this pilot!
posted by peppercorn at 4:32 PM on January 8, 2018 [5 favorites]

Thanks for this, The Whelk, such a bright story in all the darkness!

What the Hell Are Various Reasons

A lot of homeless have serious mental health issues, and find it difficult to live alone in an apartment. Even the guy interviewed in all three articles mentions that he still drops by the hospital "just to visit". I've interviewed homeless people who can't stand being indoors for extended periods, others are lonely, some have alcohol problems that eventually lead to complaints from neighbors. My fearless students once went "to have dinner" at a house a homeless person had borrowed, and he proceeded to light a fire inside the house so "he could cook".

Also as it says in the article, a lot of homeless people are really really ill. They die young.

Some people are trying to design housing that suits the homeless better, but it doesn't fit in everywhere. We often see the tiny house movement as a hipster trustfund baby thing, but it seems to work well for some homeless people.
posted by mumimor at 4:50 PM on January 8, 2018 [9 favorites]

Not to abuse the edit window: one reason some good people are critical of tiny house projects for homeless people is that they are essentially built as slum from the outset. It's not hard to imagine how some of these projects will look after 20 years. However, when the alternative is homelessness rather than nice air-conditioned apartments, many think the solution is supervision and care rather than higher standards of building.
posted by mumimor at 4:58 PM on January 8, 2018 [7 favorites]

one reason some good people are critical of tiny house projects for homeless people is that they are essentially built as slum from the outset.

This is one of the problems. On the one hand, pretty much any housing is better than no housing. Stable access to a roof, a sink, and a locker can go a long way towards reintegration into society. On the other, the tiny house movement works to evade actual housing regulations, many of which exist for good reasons.
posted by ErisLordFreedom at 5:13 PM on January 8, 2018 [6 favorites]

I too want to see better data on this. There is a current meme going around certain academic circles that goes:

WHAT DO WE WANT?

Policy decisions based on data!

WHEN DO WE WANT THEM?

Prior to the implementation of policies!
posted by ITravelMontana at 5:16 PM on January 8, 2018 [22 favorites]

I thought they had been doing this for almost 10 years in NYC. That impression is based upon seeing a snipet of news/documentary film about it from about 10 years ago.
posted by Pembquist at 5:34 PM on January 8, 2018

There keep being these pilot studies that show that giving people housing and doing medical outreach to the people who are always in the ER are way cheaper than providing high-cost emergency services; it would be wonderful if that could turn into policies providing that level of safety net nationally.

Ha ha, or we could give the ultra rich a huge tax cut, whichever is easier.
posted by Dip Flash at 5:55 PM on January 8, 2018 [24 favorites]

On the other, the tiny house movement works to evade actual housing regulations, many of which exist for good reasons.

What reasons, specifically, are you thinking of? I mean, there are certainly some aspects that convey such as fire safety and basic construction standards, but I'm curious how widely-prevalent square footage restrictions or laws designed to exclude mobile homes on otherwise-acceptable residential property qualify as "good reasons". Housing codes can be a force for good, but there's a whole lot of racism and class discrimination baked into our system.
posted by sysinfo at 6:43 PM on January 8, 2018 [2 favorites]

I mean, there are certainly some aspects that convey such as fire safety and basic construction standards, but I'm curious how widely-prevalent square footage restrictions or laws designed to exclude mobile homes on otherwise-acceptable residential property qualify as "good reasons".

Many of the square-footage laws are not "good reasons." Laws requiring a certain level of sanitation facilities are, along with requirements for heating and such, that go with "housing" and not "mobile storage unit." There are also weatherproofing issues - in CA where I live, a tiny mobile box isn't likely to be earthquake-proof, and they're not likely to be flood or snow resistant, if those are relevant.

I'm thinking fire safety, weather safety, electricity safety, minimum standards of access to heat and water, that kind of thing. They should be adaptable, but the core they're based on is "you cannot build a deathtrap and sell it to some poor sucker who can't afford a house that's fit to live in."

I'm still firmly in camp "roofs are better than no roofs," but I can understand why city authorities are twitchy about formally authorizing living spaces that aren't up to living-spaces-codes. Giving them the formal OK means opening it up for predator slumlord investors to start looking for targets.
posted by ErisLordFreedom at 7:23 PM on January 8, 2018 [12 favorites]

Chicago also has a history of these programs, this is not the first. I think the previous programs run through AFC and afflicaited agencies are older than ten years though they were more targeting disabled homeless and those with HIV/AIDS than high utalizers.

That's really been the big shift in the last 5 or so years, is the focus on high utalizers of homeless and ER services. It is 1) easier to demonstrate cost effectiveness 2) they are likely to be homeless that have the most chronic mental health and physical health problems so lots of room for improvement 3) it makes for great PR for example: man homeless for ten years gets permanent housing. 4) It's estimated that 6 percent of the homeless population uses 50 percent of services.

It has in Chicago created a gap of services for those who are not the most severe. There are less preventative programs than their used to be. So, while there is a huge problematic set to be focused on, there are lots of homeless adults getting worse who we aren't currently serving very well if at all.

I think the idea was that once the highest utalizers were moved into housing (big picture here) the services would be available for everyone else. But at this point, with the budgets in IL and everything else that hasn't been true.

I really hope these programs continue and the agencies doing them do great work!
posted by AlexiaSky at 7:45 PM on January 8, 2018 [3 favorites]

"one reason some good people are critical of tiny house projects for homeless people is that they are essentially built as slum from the outset."

One solution would be to create a tiny house community where 50% of the units were for the homeless and 50% of spaces were for tiny house builders to park their houses. There's pent-up demand for legal urban parking for tiny houses, and one of the things that makes subsidized housing work well (rather than turn into a slum or a ghetto or "the projects") is when it's mixed in with "regular" housing or when middle-class people also utilize the subsidized units.

Have the homeless organization that runs the subsidized housing host weekly community dinners in the common building, where everyone pitches in over the course of a month to cook or clean. And then as a condition of the lease for the "regular" units/spaces, require people to attend at least two dinners a month. Now you've building a community and creating connections, which gives the homeless social access to people with jobs and resources (which doesn't fix things directly but those social connections are important), and you're building a community of advocates among the wealthier residents who understand the problems of homelessness, poverty, substance addiction, etc., and who are invested in solutions that help their neighbors. And, again, it doesn't fix everything, but those people who live there a year or two carry that experience onwards into their lives when they're 40 and have three kids and have moved six states away and own a regular house and are running for city council.
posted by Eyebrows McGee at 6:53 AM on January 9, 2018 [4 favorites]

This program has a less than 50% retention rate. What the Hell Are Various Reasons. What happened to the four who died-- did they also enter hospice before they went. Is the hospital actually going to screen out those who are "not capable of living independently," because I feel like that's a really terrible idea. I need so much more information about this pilot!

I work with a standalone housing-first program, though not one that is run directly through a hospital system. Judging by what have seen in my work, some of the "various reasons" for leaving might include:

-Illegally subletting the apartment to others
-Being in active addiction and moving back out to areas of high drug use on the streets
-Becoming ill or injured in such a way that your apartment is no longer physically accessible
-Being evicted for misuse of the space--heavy traffic from drug dealers, destroying furniture or appliances, etc.

(More in next comment)
posted by ActionPopulated at 6:46 PM on January 9, 2018 [5 favorites]

Re screening people who cannot live independently--the reason to try to do that straight away is to save folks another round of waiting later on. My program has the ability to refer folks who are struggling with independence and/or at risk of eviction for behaviors to more supportive housing, but that involves its own set of new applications, bureaucracy, and hoping for openings. It would be great if we could get folks who needed it into supportive housing immediately, but it's hard to tell who's going to thrive independently and who is not because of the way that living on the streets exacerbates some psychiatric symptoms and masks others. For instance, I have a handful of clients now who bottle and store their own urine; that's a problem we never could have predicted until folks were housed, with room to keep bottles around. On the other hand, I could show you others who were very disorganized on the streets who are now thriving with the structure that housing provides. It's such a crapshoot, and the only way to work with that uncertainty is to house as many people as possible and see what works.
posted by ActionPopulated at 7:08 PM on January 9, 2018 [5 favorites]

So in terms of not living independently, at least with my familiarity with similar programs in the area, it literally means need 24 hour supervision or medical care, and it's pretty straight up safety issues like fall risk, fire hazards, capable of making decisions. That's about it, everything else is pretty much independent living.

Scattered site fair market rent is also an option, there isn't a reason not to use exsisting housing stock for these programs. I'm not sure how this particular program was designed.
posted by AlexiaSky at 6:07 AM on January 10, 2018