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Improving health through housing

Social determinants of health are garnering increased attention, especially as research continues to show just how much unmet social needs significantly affect our health. It is often said that zip code is more important than genetic code in determining overall health and wellness.

Arguably, nowhere is this more true than for people experiencing chronic homelessness. How can anyone be well if the most basic life fundamental isn’t being met: a stable roof over one’s head? It’s for this reason that Beacon Health Options’ Massachusetts Behavioral Health Partnership (MBHP) and the Massachusetts Housing and Shelter Alliance (MHSA) started the Hospital to Housing program.

Launched in 2016, Hospital to Housing helps chronically homeless people – specifically those who frequently use inpatient behavioral health care – access permanent supportive housing, primary and behavioral health care, and other community-based services, with the ultimate goal of improving their health. Results from a recent outcome study show promise that the program is indeed improving health and wellbeing.

Program nuts and bolts

Collaborating with MHSA, MBHP hired and trained five community health workers (CHWs) experienced in serving homeless individuals and assigned them to shelters and inpatient units in key Massachusetts communities. The CHWs meet eligible individuals wherever they happen to be – in the hospital, on the streets, or in shelters – and help them access housing and community-based services.

Specifically, the CHWs help program participants complete housing applications, address transportation challenges, solve criminal record issues that can hamper access to housing, and more.

The study and its results

To measure a participant’s health outcomes, the study reviewed claims data to discern any changes in the pattern of services one year before and one year after program enrollment. A shift in cost patterns during this period that reflects decreased use of intensive 24-hour care – while increasing the use of outpatient services – indicates individuals’ health is improving, as they no longer need the more intensive services.

MBHP compared the costs of services used by two groups of individuals with a history of homelessness and mental illness: the first group was 20 continuously enrolled Hospital to Housing program participants, and the second group included 45 individuals not enrolled in the program. The results were as follows:

1. Usage of 24-hour levels of care, including psychiatric inpatient hospitalizations and substance use disorder withdrawal management

  • A 54 percent decrease for the program-enrolled individuals
  • A 2 percent decrease for the comparison group

2. Usage of outpatient levels of care

  • A 23 percent increase by the program participants
  • A 43 percent decrease by the comparison group

However, it’s more than data that supports the program’s value. Its value also lies in the words of the people served by the program. Says one participant:

“[Working with my CHW] actually makes me not so stressed out. . . Because I know there is somebody who I could call anytime I needed to, to help me. And before her, I had nobody to call.”

Lessons learned

The study’s results support the view that something as basic as housing can improve a person’s wellbeing. The US spends approximately $3.5 trillion a year on healthcare but spends a relatively small share of its economy on social services that provide citizens with basic resources, such as stable housing, nutritious food, and transportation to doctors’ appointments. Further, Americans have the lowest life expectancy and more chronic health conditions among comparable countries, including Japan, Switzerland, Sweden, Germany and more.

Such data provides food for thought. Where do Americans want to spend their hard-earned dollars to improve their health and wellbeing? If the ultimate view is to shift to a model that pays closer attention to social determinants of health, the behavioral health industry – with its many touchpoints across the healthcare and social services continuum – is well poised to take the lead in changing that dynamic.

17 Comments. Leave new

Janet Plotkin-Bornstein, PhD
October 21, 2020 7:00 pm

I very much appreciate what seems to be Beacon Health’s attunement and sensitivity to the mutually influencing nature of psychological and so-called external, social factors. Thank you for this wisdom.


This sounds like a great program. I had four elder women in my practice who, for different reasons, were de-housed in 2019. It was agonizing to try to help them, mostly because there is insufficient housing. While this may be a start, the real issue to address is simply getting the state to provide more simple housing. Until we do that, people will be on the streets or staying in places that don’t give them a place to call their own. Builders who have so-called “affordable housing” units are well above what is feasible for elders living on social security. So that is not workable. It needs to be well-funded housing.

MaryBeth Stemp
October 21, 2020 7:16 pm

This work is essential. Hospital to Housing is going to help all of us! Thank you for sharing this article.

Barbara Anderson
October 21, 2020 7:17 pm

This premise seems so obvious that it is hard to comprehend why there is not more support from our governmental entities. We have seen the benefits in a small privately funded project in our rural community, but unfortunately it was not picked up by our local city or county government. Even when they are shown the way, they drop the ball.

Doreen Plante
October 21, 2020 7:29 pm

Absolutely! This is a much needed initiative! As a clinician in a zip code with little to no available housing for clients with chronic mental illness, I witness the upset and frustration of clients where lack of housing has resulted in crisis and has such a negative impact on the physical, mental and emotional wellbeing of the individual. On the flip side, I have experienced the amazingly positive results for clients when housing is provided. The gratitude expressed and improved overall condition to have a place to call home is significant.


I worked with homeless individuals with a number of challenges (HIV, addiction, mental illness) for 20 years.
In my experience, CBOs are in an optimal position to succeed with this population, being able to provide a number of essential services in a low-demand environment. Many homeless people are suspicious of institutions such as hospitals, but more comfortable with smaller, more personal environments.
The main problems that we ran into had to do a severe lack of housing of any kind (supportive, independent, etc)


I have been on the board of a shelter for the mentally ill homeless, here in Los Angles where we have a large population of homeless people so I have a good idea of the problem. I really appreciate learning this community service and only hope you expand it to other staates.


I would like to see Beacon and other insurance companies embrace case management for the mild/moderate clients in our care. Our clients who are unsheltered are sleep deprived and need support beyond one hour a week in my office. Even the recently housed need assistance in orienting themselves to the world of the sheltered.

“Suffering from a lack of sleep, just how is a homeless person supposed to do all the things necessary for overcoming their homelessness?” asks Kevin Barbieux, who writes under the name The Homeless Guy.

Judith Bergson
October 21, 2020 7:53 pm

A wonderful area to focus on!
We must not forget those families who are poorly housed as well as those
on the verge of homelessness.


I applaud all the achievements. In Orange County we have system starting with inpatient level of care the Residential Rehabilitation outpatient level of care on to Board and Cares and Room and Board and then Independent Living. I work as a Beacon employee so Beacon is also involved in this program with an aim of independent living.


This is absolutely necessary and essential for patients to have such a great resource to help them maintain stability and mental health wellbeing. Too often homeless has plagued, especially the marginalized and underserved. Way to go BEACAN!!!


I am impressed. Makes me proud to be a provider for a company with a longer view of health, treatment and prevention. Mostly, I hope initiatives such as this make a positive difference in people’s lives!

bernadette golden
October 22, 2020 1:19 pm

Homelessness is more often a cause, not an effect of mental health issues. To be housed and safe is the most basic of necessities, yet our country has allowed homelessness to continue. It’s way past time to end homelessness in America. Glad to see Beacon contributing to that.


I thought the key was ‘we had someone to call if we had a problem. If they just knew
they had that support system they didn’t need to make that call.


This is a worthy cause! Great job!


It is great to hear that Beacon is taking steps toward meeting the challenge of locating affordable housing for the homeless, and especially those with mental health issues. Bravo! Now, if you can persuade some of the other large health insurance companies to provide funding, or get on board, this problem might soon become a lost reality. Thanks!


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