Redesign of a Primary Care–Based Housing Intervention to Address Upstream Housing Needs

Abstract

Summary The stark inequity in safe, affordable housing due to unfair policies and practices (e.g., redlining) underpins inequities across multiple social determinants of health (SDOH) and health outcomes. Suboptimal housing is associated with poorer health, less effective health care engagement, and higher health care costs. In response, some health care systems address patients’ housing needs. Since 2018, Brigham Health’s social care team (SCT) has been supporting 15 primary care practices to address patients’ SDOH. Rather than focus only on unhoused patients, Brigham’s housing program also supports patients who are at risk of eviction or living in unsafe or unhealthy housing conditions (i.e., upstream factors) to prevent illness by addressing housing needs before they become a housing and health crisis. Most patients reporting housing needs are at risk of eviction or housed in unsafe or unhealthy conditions; however, intervening with this group is complicated by the number of identified needs of varying acuity and the scarcity of affordable housing. Here, the authors describe the efforts of Brigham Health’s SCT to redesign housing intervention by triaging cases to identify patients whose housing needs acutely affect their health and for which there are potential remedies and to accompany and support patients to pursue those remedies. Via a team-based process improvement project, the SCT refined its housing intervention to better direct its housing advocates’ deep expertise toward patients who could benefit most from their support. Data revealed inefficiencies in the original intervention design. Using Plan–Do–Study–Act cycles, they designed a triage protocol guided by well-defined housing case types. This team-based triage approach preserved housing advocates’ effort and expertise for complex housing situations — enabling upstream intervention, which many health care–based interventions do not focus on. The authors describe their learning process and offer recommendations for systems expanding SDOH screening with limited resources for addressing housing needs. They did achieve some positive outcomes: 14.1% of 262 cases obtained a housing accommodation, and 16% were permanently housed (8% accepted a new housing placement offer; 8% avoided eviction and maintained stable housing). However, at the conclusion of this study, they had unclear outcomes for many patients: 13.3% were lost during follow-up procedures, and another 53.4% were on housing waitlists. New efforts, supported by additional funding, will include a mixed methods evaluation that provides a difference-in-differences analysis of associations between housing program participation, health care utilization, and health outcomes, as well as interviews to better understand patients’ experiences.