Primary-care-based housing program shows promise in addressing social determinants of health

Brigham researchers found that participation in a housing program was associated with fewer outpatient visits, improved physical and mental health, and stronger connections to their primary care clinics and care team. 

Lack of safe and affordable housing is a critical issue in the United States and creates immense challenges for patients' health, well-being, and ability to access care. Investigators from Brigham and Women's Hospital, a founding member of the Mass General Brigham healthcare system, evaluated data from a social determinants of health screening and housing intervention program initiated in 2018 to help prevent homelessness and improve health care utilization and outcomes. 

They found that in this primary-care-based program for patients who were unhoused, facing eviction, or living in unsafe housing conditions, those who received integrated support from the program's care team had fewer outpatient visits, reported better physical and mental health, and felt more connected to their health care clinic and clinical team. The results are published in Health Affairs. 

It is very hard to get a patient's blood pressure under control if they are worried about where they are going to sleep. A person's health is extremely at risk if their housing is unstable. And since the pandemic, there has been an enormous increase in housing needs." 

MaryCatherine Arbour, MD, MPH, study's lead author, medical director of the social care team at Brigham and Women's Hospital's Primary Care Center

In 2018, Brigham and Women's Hospital began screening every MassHealth patient to address social determinants of health (SDoH), a term for nonmedical conditions that influence a person's health, such as housing, education, employment and transportation access. ,The Brigham's 14 primary care sites all conduct SDoH screening annually for every MassHealth patient. Four of those practices have expanded the screening to all primary care patients. The housing crisis is acutely evident in these screenings. Housing referrals fielded in this screening jumped from 20 per month in 2020 to 350 per month in 2023. 

As part of this program, a Social Care Team, including housing advocates, address patients' social needs in partnership with clinicians. Patients with a need for housing who are referred by staff or their doctor receive housing information from a Community Resource Specialist, and a subset of patients with imminent eviction risk or unhealthy conditions receive more specialized and intensive support from a housing advocacy team. Housing Advocates support patients for six months by addressing their housing needs and helping them with clinical care navigation and management. The care team works with a variety of community partners, including legal representation, to help find housing solutions. 

"What makes this program special is that it is embedded in primary care and uses a triaged approach to identify housing types that are more likely to be affecting someone's health," said Arbour. "It is a unique, integrated approach that partners community resource specialists and community health workers with the primary care team and partners the primary care team with community-based partners, including legal partners." 

To evaluate the program's impact, Arbour and co-authors conducted a mixed-method, retrospective cohort evaluation study and looked at a sample of 1,139 patients over age 18 with housing-related needs who enrolled in the program between October 2018 and March 2021. The cohort was mainly comprised of female, non-white, and non-English-speaking MassHealth patients with more chronic conditions and higher emergency room use than the general population. The evaluation looked at associations between patients' participation in the program and their utilization of health care services and chronic disease management. It also reviewed patient charts for data on housing issues, services, and outcomes, and conducted interviews that included questions about their living situations, health status, and social supports. 

Participation in the program was linked to 2.5 fewer primary care visits and 3.6 fewer outpatient visits per year, including fewer social work, behavioral health, psychiatry, and urgent care visits. Patients also expressed mental and physical health benefits as a result of being placed in new housing, and many felt a closer connection to their primary care clinics and teams, partially due to the compassionate guidance received from the housing advocates. Another outcome was that often the first housing solution for the patient was not stable or healthy, which speaks to the complex magnitude of the unaffordable housing situation. 

"The reduction in outpatient care was driven mostly by less urgent care, behavioral health, and social work utilization which suggests that the program is having important effects on mental health and behavioral health," said Arbour. "Our housing advocates are amazing. Their ability to connect with patients in very stressful situations and provide them with empathy, respect, and compassion makes a big difference." 

The study's limitations included a small sample size, short-term follow up, restricted data set, and self-reported data. The investigators also recognize that the program's interventions do not address the root causes of housing insecurity and health disparities. 

With primary care burnout on the rise, the research team plans to next explore the effects of a housing program on clinical staff and providers to see if it might also be associated with feeling more supported in confronting distressing situations with patients. 

"Being unhoused or at risk of homelessness is incredibly stressful and detrimental for mental health," said Arbour. "The most compelling aspect of the study to me was hearing the patients' stories and reflections. They not only felt their physical and mental health improved as a result of the program, but they felt a sense of belonging and truly cared for by their primary care clinic."