‘Housing First’ Advocates Look to Expand, Take Program Statewide

Finding homes for the homeless is seen as first step toward improving health, lowering costs of medical and social services

Credit: Amanda Brown
Assemblyman Louis Greenwald (D-Camden)
An effort to improve the health of the homeless in New Jersey is gaining the attention of legislative and insurance-industry leaders, laying the groundwork for the statewide expansion of a program that concentrates on finding housing for the homeless before focusing on healthcare services.

Housing First, which has seen success in the Trenton area, is scheduled to expand to Camden next year. And advocates point to a growing body of evidence that it would be a cost effective way to reduce homelessness and improve healthcare quality and costs across the state. They say existing sources like Medicaid and money used to fund shelters could instead be put to provide permanent housing.

The program provides housing to homeless people, as a first step to addressing their healthcare and other social-service needs. Traditionally, public assistance for housing the homeless has been used as a potential reward for residents, but these approaches — unlike Housing First — have been ineffective for those with addictions and other behavioral-health needs that lead to a cycle of expensive treatments.

Assembly Majority Leader Louis D. Greenwald (D-Burlington and Camden) expressed enthusiasm for expanding Housing First. He noted that the most recent count of homeless residents found 13,900 in the state. He added that many of them make frequent trips to the emergency room or require inpatient stays at hospitals, at a cost of $2,000 per day and with longer average hospital stays than patients who have someplace to live.

“By giving them the dignity of a home, a roof over their head, that sense of security, we can start to avoid those costs,” as well as additional costs from jails and other services that are required to help homeless residents whose mental-health needs aren’t addressed, Greenwald said.

“It’s really a very simple solution,” in which the state, county and local governments work together on Housing First, including a cost-benefit analysis, Greenwald said, adding that the state has vacant buildings in need of reuse.

Greenwald described to advocates at a gathering in Trenton yesterday a future path for making the program grow, by building a body of data that shows its cost effectiveness.

“We need to show the effects of this, show the impact of it, show that it saves money on the correctional facilities, that it saves money in the healthcare community,” Greenwald said.

Greenwald indicated that the Medicaid Accountable Care Organization demonstration project, which is launching next year, is a precedent that would be used to convince Gov. Chris Christie to back Housing First. That project also attempts to better coordinate healthcare to improve patients’ health and lower costs.

In response to a question about how he would make the case for Housing First to Christie, Greenwald said the project “is not going to be within the norm of the confines of the Republican Party. We’re going to give housing, we’re going to give services, it’s a social program,” Greenwald said. “But it’s got a business plan that works.”

Greenwald said using the success of the local pilots would help the state to coordinate across different departments “to try something different and outside the box.”

Greenwald is working with Dr. Jeffrey Brenner on the issue. The Camden doctor helped launch the Good Care Collaborative as part of a broader effort to put the focus of healthcare on treating low-income patients before their chronic illnesses lead to costly hospital stays. The collaborative is advocating for changes to how the state provides healthcare to low-income residents.

Brenner said no medical program would be able to reduce the repeated hospital stays of homeless residents until they’re in safe housing. He cited national figures that roughly 90 percent of Housing First recipients remain in their homes, while only 10 percent of those who stay in shelters have “housing that works for them.”

Brenner added that providing housing could help prompt a historic shift in medicine, comparable to the end of the widespread use of leeches for bloodletting, or the having surgeons operate without washing their hands.

“I think we will look back on this era and realize that the idea that we took stressed-out, chronically homeless people and put them in homeless shelters and that it made no sense,” Brenner said.

“All of the evidence supports the idea that chronically homeless people need to go directly into an apartment, in a housing-first strategy and have supportive services wrapped around them, and that you do more harm to them when you take chronically homeless people and put them into a homeless shelter,” he said.

“Homeless shelters for the most part, should be closed, and those dollars reallocated to a Housing First model,” Brenner added.

The program has drawn the interest of one of the state’s largest Medicaid insurers, UnitedHealthcare Community Plan. Jennifer Kuhn, its CEO in New Jersey, said the corporation has worked with data from across the country, which reveals that housing makes a difference for homeless patients. She noted that the company spends a considerable sum for case managers to reach patients who can be hard to find.

“I can’t tell you the number of days they come into my office frustrated, because they can’t find people,” she said.

Kuhn said the company is looking for ways to connect its resources with local providers.

Mark Humowiecki, executive director of the Good Care Collaborative, said Housing First would strengthen a broader effort to use nurses and social workers to provide in-person services to the people with chronic illnesses who use the healthcare system the most.

“Too often housing is seen as something that you graduate to,” after successfully participating in an addiction treatment program, rather than as a basis for treatment, Humowiecki said. “Too many of our patients fail that program.”

Officials with Greater Trenton Behavioral Health, an organization that works with Housing First residents, said early participants in the program saw a 78 percent decline in annual hospital inpatient and emergency costs after being provided housing. The organization hosted a Good Care Collaborative meeting yesterday to discuss Housing First.

Greater Trenton Behavioral Health housing director Vivienne Stewart said having social workers help residents find housing also helps build trust, which is a necessary step for people who feel they’ve been lied to in previous programs

“They can work towards things in their life and they’re not afraid of losing housing,” Stewart said, adding that providers have to recognize that residents will make mistakes. “We have to learn to stick with people and roll with it.”

Trenton resident David Elliott, a 45-year-old Housing First recipient, said his emergency room visits have fallen from more than once per day to less than once per week as a result of the program. He has sickle-cell disease, a condition associated with acute and chronic health problems such as severe infections and pain, but was also addicted to drugs before joining the program.

“It’s a tragedy,” Elliot said of homelessness. “To be homeless, it’s not a pretty thing, so when somebody comes along and gives you a chance to have your home and to live independent, I just think you have to be grateful for that. And I am.”

Greater Trenton Behavioral Health president and CEO John Monahan said the key to ending chronic homelessness in the state is to break down the “silos” that separate healthcare and other social programs and to make more efficient use of the money being spent on high-cost patients.

Monahan said expanding Housing First should be part of a broader overhaul of how the state serves low-income residents. He called for the state to remake its Division of Mental Health and Addiction Services into a “Division of Integrated Services,” because it must integrate these services into the rest of healthcare.

An example for New Jersey is New York, where the state government has shifted $75 million to $95 million per year in money that the state had been spending on Medicaid into housing for homeless residents who had been using Medicaid the most.

“It’s about getting that state commitment,” said Kristin Miller, New York and New Jersey director for the Corporation for Supportive Housing, which supports programs like Housing First.

Richard W. Brown, CEO of Camden-based Monarch Housing Associates, which connects homeless residents with housing and services, said there is a precedent for making gains in eliminating homelessness — the ongoing national effort to end homelessness for military veterans. But he said it would take more than existing funding to achieve this goal. “It’s simply because we invested new money,” that the number of homeless vets has dropped, he said.