Lack of safe and affordable housing in the United States creates immense challenges for patients’ health, wellbeing, and the ability to access care. Investigators from Brigham and Women’s Hospital evaluated data from a social determinants of health screening and housing intervention programme, which launched in 2018 to help prevent homelessness and improve healthcare utilisation and outcomes.

For patients who were unhoused, facing eviction, or living in unsafe housing conditions, those who received integrated support from the programme’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’s very hard to get a patient’s blood pressure under control if they’re worried about where they’re going to sleep,” said the study’s lead author, MaryCatherine Arbour, MD, the medical director of the social care team at Brigham and Women’s Hospital’s Primary Care Center. “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.”

In 2018, Brigham and Women’s Hospital began screening every MassHealth patient to address social determinants of health (SDoH) – the non-medical 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, and four of these practices have expanded the screening to all primary care patients. Housing referrals fielded in this screening jumped from 20 per month in 2020 to 350 per month in 2023.

As part of this programme, 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 specialised 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 community partners, including legal representation, to help find housing solutions. 

“What makes this programme special is that it’s 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’s 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.”

Programme impact

To evaluate the programme’s impact, Arbour and co-authors conducted looked at a sample of 1139 patients over the age of 18 with housing-related needs who enrolled in the programme between October 2018 and March 2021. The cohort mainly comprised 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 programme and their utilisation of healthcare 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 programme was linked to 2.5 fewer primary care visits and 3.6 fewer outpatient visits per year, including fewer social work, behavioural health, psychiatry, and urgent care visits. Patients also said their mental and physical health improved as a result of being placed in new housing, and many felt a closer connection to their primary care clinics and teams.

“The reduction in outpatient care was driven mostly by less urgent care, behavioural health, and social work utilisation, which suggests that the programme is having important effects on mental health and behavioural 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, a restricted data set, and self-reported data. The investigators also concede that the programme’s interventions do not address the root causes of housing insecurity and health disparities. 

The researchers also plan to explore the effects of a housing programme on clinical staff and providers to see if it might be associated with feeling more supported in confronting distressing situations with patients. 

Arbour reflected: “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 programme but they felt a sense of belonging and truly cared for by their primary care clinic.”