By Leah Giacomino, DMSG Student Intern
Impact of Social Determinants of Health on Housing Instability and Homelessness
The Social Determinants of Health have a large impact on housing instability and homelessness. “The Social Determinants of Health are the conditions in the environments where people are born, live, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks” (Social 2021). Housing instability includes trouble paying rent, overcrowding, moving frequently, staying with relatives, or spending the bulk of household income on housing (Office 2020). Homelessness and housing instability have a variety of causes and effects. They require complex solutions that are systemic and tackle more than just individual parts of homelessness or housing instability.
Homelessness can be caused by a multitude of things, many of which are outside of peoples control. It can be caused by stagnant wages, unemployment, lack of affordable housing, lack of affordable healthcare, poverty, lack of mental health and addiction treatment, racial inequality, domestic violence, family conflict, and systemic failures (Soken-Huberty 2020). It can also be caused by involvement of the justice system, sudden serious illness, divorce, death of a partner, and disabilities. People without adequate housing may live in unsafe conditions and have trouble getting access to healthcare, food, and with staying safe (U.S 2021).
Income is the single largest social determinant of health. People are only as healthy as they can afford to be so impoverished people are at a sever disadvantage. Housing instability can be caused by stagnant wages which means that costs go up, but wages don’t so people aren’t able to afford housing. That also means that they aren’t able to save any extra money, so they are trapped in poverty (Soken-Huberty 2020). People can become unemployed for various reasons and unhoused people want to work but have a hard time finding it without a permanent address (Soken-Huberty 2020).
There is also a lack of affordable housing. People with the lowest income may also be forced to rent poor quality housing that can expose them to things like vermin, mold, water leaks, and inadequate heating or cooling systems. Rising housing costs and the inability to afford housing can lead people to be evicted or foreclosed on. Having unsafe and unstable housing can lead to a variety of health problems (Office 2020). Healthcare is expensive, so people struggling to pay for housing really don’t have any extra to spare for their health. That means that they can neglect going to the doctor and ultimately have worse health issues that escalate and become even more costly. There is a lack of mental health and addiction treatment services for people experiencing homelessness (Soken-Huberty 2020). Without managing these things, people can have behavior issues and make it hard to earn a stable income and have stable housing. Veterans can also experience homelessness. When they return to a civilian life, they may find it difficult to find affordable housing and a livable income. They may also suffer from mental health issues, PTSD, drug or alcohol abuse, and other health problems (Homeless 2021).
Racial inequality and racism are also big issues. Minority groups, especially African Americans and Indigenous people experience homelessness at higher rates because of historical and structural racism (Homelessness 2020). They have been denied the same socioeconomic opportunities as white people. African Americans also have experience discrimination in housing. They still live disproportionately in concentrated poverty or in neighborhoods where they are regularly exposed to environmental toxins, and have limited access to quality care, services, nutritious food, and economic opportunities. People that become homeless are likely to have lived in these types of neighborhoods. People of color are often shown fewer rental units, and denied more leases compared to white people who are offered lower rents. African Americans are also over criminalized, targeted or profiled, and incarcerated. Then after they get out, it can be extremely hard to secure employment and reliable housing. People of color are also more likely to lack health insurance than white people which makes it harder to treat medical conditions and manage mental and chronic health problems (Homelessness 2020).
Family conflict can cause teens to run away or be kicked out. Teens may experience family problems, economic problems, and residential instability (National 2008). Family problems may include physical and sexual abuse, strained relationships, addiction of a family member, and parental neglect. Some of them were kicked out or their parents told them they didn’t care if they left, so they ran away. Some youth experience homelessness because their families are having a financial crisis, but they are usually separated from them by a shelter, traditional housing, or child welfare. Residential instability is when youth in foster care or other institutional placements age out of the system and have nowhere to go, so they become homeless. Youth also have trouble earning money legally and may engage in sexual activity in return for food, clothes, and shelter, making them at greater risk for contracting AIDS and HIV. They may also suffer from anxiety, depression, malnutrition, and poor health. Adolescents facing homelessness need the same support programs as adults, and they can benefit from education programs and child welfare programs (National 2008).
Domestic violence can also be a factor – many people who experience DV and experience homelessness find it to be a step up since they are away from an abusive setting. Domestic violence is a huge cause for women and children to become homeless. They want to leave the abusive setting but often have little money to afford a new place that is safe (16 Things 2017). Emergency housing shelters are often the first stop for women fleeing violence, but when the shelters are full, they have to decide between going back to the abuser or risking homelessness. Survivors often face discrimination that results in eviction or denial of housing because the landlord doesn’t want to deal with it. Generally, local domestic violence emergency shelters help women come up with a long term plan for safety before they leave an abusive partner for good, and they can often help set people up with resources to find housing assistance (16 Things 2017).
Homelessness and incarceration can often be intertwined (Peiffer 2020). People experiencing homelessness may be arrested for low level offences like loitering, sleeping in parks, or public urination. Without the right social programs, people just call the police to respond to people living outside. People who were incarcerated often face housing and job discrimination when they get out so they also may experience homelessness – they are even more likely to do so if they have multiple convictions. This is problematic for the people experiencing incarceration and homelessness, and it is expensive for taxpayers. These people require the services of jails and emergency services which is very expensive for the city. People experiencing these things need permanent support programs to help them get out of the cycle of incarceration and homelessness (Peiffer 2020). Veterans may also experience homelessness.
Systemic failures are also a problem. Homelessness can occur when people don’t have the correct support in society. There can be failures in correctional services, healthcare, child welfare services, and more. If the society does not address racial inequality, increase wages to be livable, and provide affordable housing, homelessness rates will continue to rise (Soken-Huberty 2020).
Covid has put more people at risk for becoming homeless. Many people have become unemployed during the pandemic, so there was a surge of evictions, but a federal order halted evictions from September to March since there simply weren’t enough shelters and places for people to go. That didn’t stop landlords from deciding to not renew a lease or to evict people for other lease violations (Chuang 2021). During COVID, less people experiencing homelessness were incarcerated because jails wanted to lessen the likelihood of exposure. Communities have the opportunity to create more equitable and sustainable options to stop using punitive tactics to trap people in a cycle of homelessness and jail like using a housing first strategy; but without those social programs already in place it seems unlikely unless community leaders are lobbied to make changes (Pfieffer 2020).
The social determinants of health include behaviors, the healthcare system, genetics, income, community, environment, and education (Gabow 2021). Some behaviors like substance abuse and addiction can increase the likelihood of homelessness. The healthcare system can also be a problem when people don’t have access to care, or they can’t afford the high costs. People can be genetically predisposed to having mental illness or addiction. Income is the biggest social determinant of health. People can lose their jobs, or they just can’t afford housing or rent. Community studies report that lower income neighborhoods report lower health outcomes. The environment is also a factor because people experiencing homelessness often have poor living conditions and are exposed to the elements. Education can have a domino effect. People with low education are more likely to face unemployment which makes it much harder to afford housing (Dukes 2018).
People experiencing homelessness or housing instability can also experience a variety of health problems. People may not have access to care because they have no transportation or way to get to a clinic or provider or they can’t afford; or they at least can’t get there consistently to have a good continuum of care (Schrag 2014). The ER has to treat people and they have more hours than a regular primary care provider, but that isn’t a very good solution because it is overall more expensive for the people using the service, it’s more expensive for the healthcare system, and it slows down care for people who are actually experiencing an emergency. It would be better if people utilized more primary care providers, but people may experience barriers to that. People who are experiencing homelessness or housing instability may face food insecurity so they can’t afford nutritious food and can often be malnourished, so they aren’t able to stay healthy (Schrag 2014). They can develop chronic conditions and comorbidities which are multiple conditions, that become expensive and harder to manage. Things like lung disease, bronchitis, tuberculosis, pneumonia, and HIV are just some of the conditions that are common among people experiencing homelessness (U.S 2021). They have to live in unsanitary and unsafe conditions (U.S 2021). And they experience higher mortality rates than people who have secure housing. People experiencing housing instability may be in unsafe or overcrowded housing.
There are some programs or solutions out there that are just band aid solutions that don’t look at the root of the problem and only help with certain aspects. However, that is not to say that they aren’t helpful or necessary. They are only single parts of a solution. There are also more coordinated or systemic solutions which can be a collection of band-aid solutions working together to create more comprehensive network of tailored solutions based on individual need. There are also other aspects like housing first, homeless prevention, and screenings at hospitals and schools for the social determinants of health.
They provide healthcare to vulnerable populations that otherwise may not have access, transportation, or money to pay for care. Mobile health clinics save the healthcare industry $12 for every $1 spent in a mobile health clinic setting. Giving people access to primary care also prevents 600 emergency department visits a year, which avoids the $200 per ED visit cost (Heath 2019). They rely on community partnerships to provide services where they are needed effectively, and to establish trust among patients so they actually utilize their services. They can provide primary care, dental, maternal care, and some chronic care (Heath 2019).
In Colorado, Centura Health offers mobile care (DispatchHealth 2021). To get access to a mobile unit, people just have to call or use the app, explain their symptoms, and a mobile medical team will arrive in about an hour. The medical professionals on the unit are ER trained and can treat anything an urgent care could. They have multiple locations across various states. But the ones in Colorado serve mostly the greater Denver area. They can also call in prescriptions and handle billing with health insurance (DispatchHealth 2021). It is as affordable as going to an urgent care, so it only helps with the barrier of access to care.
There are also free clinics across the US. These are facilities funded by the state and federal government, so people are covered even if they don’t have insurance (Search 2021). And there is a sliding fee scale for people who have an income. The Federal Poverty Guidelines affect how much people pay. Some clinics have essential services for no fee at all. There are services like checkups, treatments, immunizations, prescriptions, and more depending on the facility. It seems that all of the facilities are independently owned and operated. One of these clinics includes the Stout Clinic in Denver. This particular clinic offers primary care, behavioral health care, child health care, dental services, a pharmacy, eye care, substance abuse recovery, and transgender health care, for people experiencing homelessness (Types 2021).
Medical respite or recuperative care is acute care for people experiencing homelessness who need a safe space to recover from an injury or illness. They may be too ill or frail for the streets, but not enough for a hospital so they can rest in a medical respite facility which can include a freestanding facility, homeless shelter, nursing home, or transitional housing (Dobbins 2021).
The Colorado Coalition for the homeless has a medical respite program. They are funded by Hospital, HRSA, Medicaid/Medicare, United Way (Colorado 2021). They have three locations in Denver: Beacon Place, the Samaritan House, and The Crossing at Denver Rescue Mission, where they serve people who are experiencing homelessness and need a safe place to recover after being discharged from a hospital. They also have support services like housing assistance and treatment programs. There are 35 beds across the three locations and the average length of stay is 45 days. For someone to be admitted they must have an acute medical condition that can be addressed in a short amount of time. They must be homeless, alert, and oriented, continent, able to function in a residential/shelter setting, clean and sober for 72 hours before admittance, over 21, and willing to follow the facilities rules (Colorado 2021).
Many people who are at risk or experiencing homelessness want to work or are employed but don’t make enough to sustain themselves. They need sustainable wages and permanent housing (US 2021). It is hard for people experiencing homelessness to find and maintain employment. There are programs that provide job training and placement programs to ensure long term stability. Barriers like lack of childcare and transportation can also contribute to unemployment (Employment 2020). Below there are resources that help families find assistance with housing, transportation, job listings, supplemental income, and more.
- Temporary assistance to needy families (TANF) recognizes that families’ housing crises are a big part of their long term self-sufficiency. ¼ of the families on TANF experienced homelessness and almost half doubled up with other households. TANF offers short term rent assistance so families can avoid or escape homelessness. And they have employment services so people can continue to pay their rent once the rent assistance ends. So, this is rapid rehousing with employment help and can help homeless or avoid homeless (Income 2020).
- Workforce Investment/innovation and Opportunity Act (WIOA) (federal program) for low skilled entry level workers. Helps low income households with childcare and transportation assistance and can have a big impact on the family maintaining a job (Income 2020).
- The Colorado Department of Labor and Employment have resources for workforce centers that have job listings, career counselling and training, and recruit workers. They also have information on other organizations that can help with health, housing, food, and legal resources (Assistance 2021).
- Supplemental Security Income: (Federal income supplement funded by taxes) It is designed to help aged, blind, and disabled people, who have little or no income; and it provides cash to meet basic needs for food, clothing, and shelter (Income 2020).
- Colorado Coalition for the Homeless – vocational services helps with employment. They can help develop a resume, career counseling, interview training, help look for jobs, job readiness training, job placement, and ongoing support once employed (Get 2021).
Homelessness and housing instability are complex problems that rely on equally complex solutions that need to be specifically tailored for the person affected (Fowler 2019). People with severe mental illness need ongoing intensive support whereas pregnant teens have a different set of needs so there can’t be a “one size fits all solution”. There are interorganizational networks made up of governmental and nongovernmental agencies with formal and informal partnerships who work together to provide housing and other support. There are temporary housing services which provide short term accommodations case management, supportive housing provides more permanent housing plus case management to address barriers to stability, and rapid housing and homelessness prevention represents efforts to provide immediate access to stable conditions. Different agencies must work together to provide a collaborative system of homeless service delivery, which can be challenging because it means that they have to work on mutual goals instead of their individual core service missions (Fowler 2019).
To end homelessness, the approach needs to have a coordinated entry (Creating 2019). This means that communities should move away from having separate individual programs to grouping the programs together for a community-wide response that is more effective, and data driven. They will have to look at data about the needs of people experiencing homelessness in order to effectively allocate resources, services, and programs. This coordinated entry also indicates a coordinated intake to quickly identify, assess, and refer and connect people to the correct programs and services regardless of which sector they originally were asking for. Communities would also need to create goals and measurement standards for those goals and identify how to integrate different programs. For this to have a wider impact on the system as a whole, it needs an information technology system. The Homeless Management Information System is an example of this; it collects local client, program, and system data on housing and other services for homeless people and people who are at risk for homelessness. “Each Continuum of Care is responsible for operating an HMIS system according to the U.S. Department of Housing and Urban Development’s (HUD) Data Standards (Creating 2019).” A common shared data system would allow for an easier look at how different programs are working and the overall system performance measurement (Creating 2019).
Some programs like the Regis Urban Camping program are closer to a systemic solution on a small scale since it looks at multiple facets. The Safe Outdoor Space at Regis has sturdy outdoor tents that can house up to 60 people. It is running from June1 – Dec 31, 2021 and is located in one of the parking lots at Regis. The space has bathrooms, sinks, food/meals, drinking water, laundry, showers, shade tents with ducted cooling, electricity, and internet. They offer daily wellness screenings, dental care, COVID testing and vaccines, hotel referrals, outreach services, homeless management intake, housing referrals, employment referrals, and benefit navigation. They help people transition into permanent housing by helping them find long term housing and employment (Regis 2021).
Housing first uses housing as a platform to connect people to other services (Fowler 2019). People who get housing first are able to get some stability back and look at other programs to help with their stability. People experiencing homelessness who utilize Housing First are not required to address all of their problems like behavioral health problems, or to graduate through a series of services programs before they can access housing – but there are voluntary programs that they can partake in (National 2016). There are different types of housing. There is permanent supportive housing (PSH) which is for individuals and families with chronic illnesses, disabilities, mental health issues, or substance abuse disorders who have experienced long-term or repeated homelessness (Housing 2016). Or there is rapid re-housing, which provides short-term rental assistance and services and serves a broader population of people. It helps people get housing quickly, increase their self-sufficiency, and remain housed with the help of case management and other services. In general, housing first interventions – or interventions that allow people stable housing as a first step improved stability for people experiencing short term and long term homelessness (Housing 2016). People participating in housing first programs are more likely to participate in job training programs, go to schools, discontinue substance use, have fewer instances of domestic violence, and spend fewer days hospitalized (National 2016). It also saves costs in communities because people who are housed are less likely to use emergency services like hospitals, jails, or shelters.
There is less data on funding of homeless prevention, and successful prevention isn’t measured. There are some select groups vulnerable to homelessness like families investigated for child maltreatment, kids aging out of foster care, and veterans returning from combat. They also focus on households facing evictions and foreclosures and low income families that are screened for housing instability- which means that they look at the most vulnerable but can ignore the unseen needs of many other households who need support. National policies generally avoid the human and social costs of timely assistance that address housing instability. Prevention efforts look at avoiding reentry to homelessness instead of looking at connections to housing. There simply aren’t enough prevention efforts – to reduce housing insecurity homelessness prevention needs to be more integrated into existing service networks and be timelier (Fowler 2019).
One prevention effort is providing rent support to households to increase their likelihood for housing security and avoid homelessness. Rental assistance can reduce crowding, poverty, housing instability and homelessness. Having rental assistance allowed 3 million people to rise above the poverty line in 2018. When people can afford housing, it makes it easier to hold down a job, afford food, medical care, and clothing. And it improves the outcomes of children, so they have better health and a better education with less overall behavior problems. They are also less likely to enter foster care than unassisted kids who can be placed in the system if their parents can’t afford suitable housing. It also allows people to move out of lower poverty neighborhoods so they can experience better health outcomes, education, and access to food and other services, and less crime. Rental assistance has also been shown to reduce healthcare costs for high users of the health system who may also experience homelessness or frequent institutionalization in nursing homes, mental health facilities, or jails. There are some limitations to rent assistance programs, since they do not always have the necessary funding to help all the people that need it. Most (60 percent) of the households who receive rental assistance have at least one worker who is able to work and is employed, and they generally receive assistance for less than 3 years. Rent assistance is also targeted at the neediest population, of which most are far below the poverty line. Rent assistance programs have the ability to vastly improve the lives of adults and children, and it is cheaper to provide funds for rent assistance than for households to become homeless and require even more support services (Fischer 2019).
In light of the pandemic, the Denver Department of Housing Stability (HOST) has expanded its federal assistance funds to households that are in need lately. The Denver City Council recently passed an Emergency Rental Assistance Program (ERAP) to Denver households who are unable to pay for their rent and utilities. Now that evictions are allowed again, this should slow the spread of them. This program supports low and moderate income households by providing funding for rent, rental arrears, utilities and arrears, security deposits, and housing stability services like case management. Denver ERAP has a total of $49,159,548.30 for households in need. People can qualify based on meeting qualifications for unemployment and financial hardship and demonstrating a risk of experiencing homelessness or housing instability. Households may be eligible for up to 15 months of rental assistance (City 2021).
Many hospitals and health care settings don’t screen for the social determinants of health, but they really should start. It is the first step towards creating more equitable care. SDOH can create barriers to care, such as with transportation, food scarcity, environmental hazards, etc. Organizations can look at their data and systems to find an area of the population that they can screen that would make the greatest impact. They could look at existing screening tools and modify them, so it works for the social determinants of health. Then they need to have social services readily available to use, and staff educated on what they are and how to point patients towards them. This will create a better continuum of care and better community health (Bradywood 2021)
It would be beneficial if healthcare settings would screen for the SDOH. More than 70 percent of a person’s health outcomes can be driven by SDOH factors (Leventhal 2020). Currently, not very many practices and hospitals screen for them – though areas that serve an economically disadvantaged populations do better with screening. Even if organizations wanted to start screening, they would need to build the infrastructure for it. Many physicians don’t know how to help or what other organizations they can point people towards. The organizations that do have screenings for this are well connected to community based organizations and resources and have social workers available to direct people. In order to increase SDOH screenings, state and federal governments would likely have to play a role in getting them implemented. Health care organizations would also have to figure out a way in which to serve people equally so that the people from one hospital wouldn’t be offered more resources than another. The network of SDOH help organizations would have to be systematic and coordinated, and there would need to be ‘network coordinators’ to help people find the programs that they need. The network coordinators would have to work across all healthcare organizations and community based organizations in the region to help the community effectively and justly. Interoperability may also be an issue. The respective EHR systems would need to be able to talk to each other for the healthcare organizations and community orgs to work together – if the suggested referral system is used (Leventhal 2020).
Only a small number of people who were facing having their utilities shut off from being unable to pay the bills were identified in the screening (Heath 2020). Utilities being turned off can affect people with asthma who may need their air conditioner/air purifier, or people with chronic illnesses who need refrigerated medications. Utilities often prolong cancelling utilities, even with unpaid bills – and medical documentation as a utility’s protection letter can keep things on for a while but not forever. And people aren’t always screened for this. This could be because they only go to the doctor so often, and things can change with the seasons, like the winter when you need gas or heat. A person might not even make it into a clinic because of transportation problems. Or the patient may not trust their doctor enough or want to tell them that they are having problems paying their utilities. These screenings need to be more accurate and complete (Heath 2020).
Montrose county school district identified 221 children being identified as homeless last year, so this program is very important (Nexstar 2021). Housing Resources of Western Colorado (HRWC), Montrose County School District (MCSD), and Hilltop Community Inc. will work together to give 2 families this year, and 3 the next safe and affordable housing and other stuff. They will also have a certified housing counselor to help each family develop a plan for their financial and housing goals, and they will receive counseling on budgets, savings, and credit improvement for long term financial stability. Case managers will also help them in fulfilling needs in social, employment, parenting, financial, health, food insecurity, and basic needs of the parents and children. The MCSD liaison will identify potential households in need of assistance to be enrolled in the program. The priority is for those vulnerable or victimized to human trafficking or sex work, vulnerable to illness or death, those with physical, mental, or behavior impairments or disabilities, risk for continued homelessness, and other factors based on severity of needs. The program will help students maintain an attendance of 85% or better and earn grades a C-grade or better. It will help kids in low income households succeed academically, maintain their health, and have financial success later in life while reducing costs in the community (Nexstar 2021).
Denver Public Schools has established the Educational Outreach Program to identify homeless families in the district and provide them with the necessary resources and services to help them get back on their feet (Chen 2021). It can be hard for local governments to identify homeless families and offer aid, but schools are in a unique position to notice this. This program gives assistance with school enrollment and advocacy for students, free breakfast and lunch for students, school supplies and backpacks, transportation help to get students to and from school, assistance with clothing or the purchase of school uniforms, and resources to help families find emergency housing options. The point of it is to help students break the cycle of poverty by having access to necessary resources. Children perform better when they have a safe place to live, sleep, and study, as well as having access to health food. It helps families get back on their feet (Chen 2021).
The Social Determinants of Health have a large impact on housing instability and homelessness. Homelessness can be caused by things outside of peoples control, largely related to income, affordability, health services, family conflict, racism, and systemic failures. The social determinants of health include behaviors, the healthcare system, genetics, income, community, environment, and education (Gabow 2021). People experiencing homelessness or housing instability can experience more health problems while not having access to affordable care. There are so many programs out there that aid people, but many of them are just band aid solutions that only look at single parts of homelessness or housing stability, so they are an incomplete solution. There needs to be a systemic and coordinated approach to tacking homelessness and housing stability. There needs to be an intertwined network of programs and solutions that people can navigate to have tailored solutions that fit them. People have different needs and require different supports. The entry point into a systemic solution should start with a housing first program since it solves the problem of housing, which allows people to look further at ither programs they may need. There also need to be more homeless prevention programs. There are some rent support programs that help people avoid homelessness, by receiving funding to stay housed. Hospitals and schools should also widely screen for the social determinants of health and help connect people to services they may need to help people have housing stability, good health, and for kids – a good education. There are a ton of programs out there, but many of them are largely disconnected so not enough people have access to all of the programs that they need.
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About the Author
Leah Giacomino is a Student Intern with the Denver Medical Study Group. She currently is working on her undergraduate degree in the Healthcare Administration Program at Regis University. (Expected graduation date: Spring 2022)