Chicago Housing for Health Partnership
The Chicago Housing for Health Partnership (CHHP) was formed in 2003 to scientifically test the efficacy of a Housing First model to improve the health of homeless individuals with chronic medical illnesses. The partnership includes hospitals, CHHP case managers, and providers of medical respite, temporary housing, and permanent supportive housing, all working in coordination with the CHHP lead agency, the AIDS Foundation of Chicago. During a three-year demonstration project phase, CHHP used an experimental design to test the model’s impact on client health outcomes and costs of service utilization in the health care system. CHHP has since evolved into a permanent, citywide collaboration of housing, health care, and social service agencies that provides assistance to more than 400 people with chronic medical illnesses who have experienced homelessness.
Problem or Challenge:
People experiencing homelessness who have serious chronic health problems are often hospitalized for medical care. After being discharged from hospitals, they may have nowhere to go to recuperate, and without stable housing they cannot effectively manage their chronic health conditions. As a result, they frequently return to the hospital for care that is very costly, and they may end up in a nursing home. The costs for avoidable utilization of hospitals and nursing homes are high, and health outcomes are poor for people with chronic health problems who leave the hospital without housing.
There have been several studies that measure the costs of health care services used by people experiencing homelessness before and after entering permanent supportive housing. These studies generally show that permanent supportive housing leads to significant reductions in the use of hospital inpatient and emergency room care. Most of these studies, however, do not meet the rigorous standards of experimental design, wherein researchers describe the impact of an intervention offered to one group of people in comparison to another group of people with similar characteristics who receive “usual care.”
The Chicago Housing for Health Partnership (CHHP) provides homeless individuals with chronic illnesses case management, medical respite and temporary housing after hospital discharge, and referral to permanent supportive housing once they are well enough to live independently. CHHP’s research partners conducted a rigorous evaluation of this program, working with two Chicago hospitals. People receiving inpatient care in these hospitals were eligible to participate in the study if they had been homeless for at least 30 days prior to hospitalization and had at least one of 15 chronic medical illnesses. Hospital social workers referred patients to research assistants who offered them the opportunity to participate in the study; 89 percent of eligible patients agreed to participate. Study participants were interviewed and randomly assigned to either the intervention group, which was linked to case management services, medical respite care, and permanent supportive housing, or “usual care”—standard discharge planning services provided by hospital social workers and referrals to community-based resources. Among the 201 people assigned to the intervention group, all received case management while they were still in the hospital, and more than 80 percent received CHHP case management services after they left the hospital. Most (75 percent) but not all of those who were assigned to the intervention group received a permanent supportive housing placement. Temporary (or interim) housing options, including medical respite programs, were made available by CHHP partner agencies to allow clients to have a safe place to stay after leaving the hospital while they completed the application process for permanent supportive housing. Some participants in the intervention group were re-hospitalized or they did not stay engaged in services that were offered by CHHP; although the program worked to re-engage participants as often as needed, and allowed for multiple stays in temporary and permanent housing in an ongoing effort to help people get and keep housing. Some study participants were unable to find housing options available from CHHP partner agencies that matched their needs and preferences and for which they were eligible.
Researchers tracked outcomes for both the intervention group and the usual care group through follow-up interviews. The researchers gathered information about the utilization of a broad range of health care and other services using a combination of interviews, electronic medical records, and other data sources, and used unit cost information to estimate the total costs of services used by both groups of study participants.
Use a Housing First approach to stabilize people experiencing chronic homelessness and use housing as a platform for engaging people in the health care and treatment services they need
The CHHP lead agency, AIDS Foundation of Chicago, and program partners met regularly to review progress in enrolling study participants and providing linkages to temporary and permanent housing for those who were selected for the intervention group. When CHHP was first implemented, some partners were not using a Housing First model but instead required sobriety. Many of the CHHP study participants faced significant challenges to achieving stability in housing programs that demanded sobriety or compliance with strict program rules. More than three-fourths (76 percent) of study participants had been homeless for more than a year, and more than 80 percent had long-term substance use problems. Program partners that were achieving better housing outcomes were using “low barrier”, Housing First program models. AIDS Foundation of Chicago provided training and technical assistance to improve providers’ understanding of and capacity to implement the Housing First model, and reallocated resources to programs that achieved better housing outcomes for participants.
Strong coordination and leadership from the lead agency and a structure for collaborative implementation and accountability
CHHP created a centralized structure to coordinate funding and client referrals to partnering agencies. As the lead agency, CHHP took responsibility for coordination and leadership, while collaborating agencies provided input through a governance board and oversight committee. The structure provided accountability and transparency for achieving the overall goals of the project. When some housing programs were more successful than others in providing housing access and achieving stability for program participants, resources were reallocated to the programs that demonstrated the best outcomes for clients.
Harness the expertise and skills of diverse partner agencies to allocate resources, solve problems, and serve clients
The CHHP partnership includes hospitals, a medical respite program, resources for both site-based and scattered-site permanent supportive housing, and providers of health care, behavioral health, and intensive case management services.
Build a systems response to provide seamless access to medical respite, permanent housing, health care, and intensive case management
A Systems Integration Team includes case managers from hospitals, temporary housing and permanent housing programs who work together to help clients as they are discharged from the hospital to medical respite or other temporary housing and into permanent housing. Case managers from all partner agencies meet weekly to review clients’ service needs and progress and communicate regularly as needed, sharing common data and record keeping.
In 2009, the Journal of the American Medical Association (JAMA) reported that CHHP participants in the intervention group had almost one-third (29 percent) fewer inpatient hospital days and one-quarter (24 percent) fewer emergency room visits compared to participants in the usual care group (1).
Participants who were provided permanent housing with case management used one-third fewer inpatient hospital days and one-quarter fewer emergency room visits than their peers who relied on the usual care system.
During the 18-month study period, the intervention group had 1.93 hospitalizations per person per year, compared to 2.43 hospitalizations per person per year in the usual care group.
The intervention group had 2.61 emergency room visits per person per year compared to 3.77 ER visits per person per year for the usual care group.
In other words, for every 100 homeless individuals offered the intervention benefits there were 49 fewer hospitalizations, 270 fewer days of inpatient hospital care, and 116 fewer emergency room visits.
The American Journal of Public Health reported that CHHP also had a significant impact on study participants with HIV/AIDS (about one-third of all study participants); reducing mortality rates and significantly increasing the rate at which people with HIV/AIDS survived with better health outcomes one year after the study began (2).
After one year, 55 percent of HIV-positive participants in the intervention group had a relatively healthy immune system, compared to 34 percent of people in the usual care group.
Compared to HIV-positive participants who received usual care, those who were in the intervention group were twice as likely to have undetectable levels of HIV in their blood, indicating that treatment for HIV/AIDS was highly successful.
In 2011 the journal Health Services Research published additional findings from the CHHP study comparative-cost analysis, which showed that the costs of providing housing and case management are more than offset by the reduced costs of hospital and nursing home services, prison or jail, and other services (3).
People in the intervention group had significantly fewer days in prison, nursing homes, and residential substance abuse treatment, as well as fewer emergency room visits and days of hospitalization, and more outpatient visits each year compared to the usual care group.
Cost savings associated with the reduced utilization of many services more than offset the increased costs for housing, outpatient care, and case management services for those in the intervention group. Cost savings were even greater for study participants who had experienced chronic homelessness.
For a summary of evidence, visit the AIDS Foundation of Chicago website.
Contact Info for follow-up:
AIDS Foundation of Chicago
Evidence-Based Practice: Permanent Supportive Housing
Evidence-Based Practice: Housing First
Evidence-Based Practice: Medical Respite
Promising Practice: Frequent Users of Health Services
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1. Sadowski, L., Kee, R., VanderWeele, T., & Buchanan, D. Effect of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations among Chronically Ill Homeless Adults: A Randomized Trial. Journal of the American Medical Association. May 6, 2009, 301: 17, p. 1771.
2. Buchanan, D., Kee, R., Sadowski, L., & Garcia, D. The Health Impact of Supportive Housing for HIV-Positive Homeless Patients: A Randomized Controlled Trial. American Journal of Public Health. June 2009, 99:6.
3. Basu, A., Kee, R., Buchanan, D., and Sadowski, L. (2011). Comparative Cost Analysis of Housing and Case Management Program for Chronically Ill Homeless Adults Compared to Usual Care. Health Services Research, doi: 10.1111/j.1475-6773.2011.01350. http://www.aidschicago.org/pdf/2009/hhrpn/CHHP/CHHPreportLoyola.pdf