Primary care-based residential program shows promise for addressing social determinants of health

Brigham researchers found that participation in a residential program was associated with fewer outpatient visits, improved physical and mental health, and stronger connections with their primary care clinics and care team.

The lack of safe and affordable housing is a critical issue in the United States and poses enormous challenges to patients’ health, well-being, and access to care. Researchers from Brigham and Women’s Hospital, a founding member of the Mass General Brigham Health System, evaluated data from a social determinants of health screening and housing intervention program launched in 2018 to help prevent homelessness and improve the use and health care outcomes.

They found that in this primary care-based program for patients who were unhoused, facing eviction, or living in unsafe housing, those who received integrated support from the program’s care team had fewer outpatient visits, reported better physical and mental health and felt more connected to their health clinic and clinical team. The results are published in Health matters.

It is very difficult to control a patient’s blood pressure if he is worried about where he will sleep. A person’s health is extremely endangered if their home is unstable. And post-pandemic there has been a huge increase in housing needs.”

MaryCatherine Arbour, MD, MPH, lead study author, medical director of the social care team at Brigham and Women’s Hospital’s Primary Care Center

In 2018, Brigham and Women’s Hospital began screening every MassHealth patient to address social determinants of health (SDoH), a term for non-medical conditions that affect a person’s health, such as housing, education, employment and access to transportation. Brigham’s 14 primary care sites conduct an SDoH screening annually for every MassHealth patient. Four of these practices have expanded screening to all primary care patients. The housing crisis is acutely evident in these projections. Home referrals included 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, addresses patients’ social needs in partnership with clinicians. Patients in need of housing who are referred by staff or their doctor receive information about housing from a community resource specialist, and a subset of patients at immediate risk of eviction or unhealthy conditions receive more specialized and intensive support from an advocacy team housing. Housing Advocates support patients for six months by addressing their housing needs and helping them navigate and manage clinical care. The care team works with a variety of community partners, including legal representation, to help find housing solutions.

“What makes this program special is that it’s embedded in primary care and uses a tiered approach to identify housing types that are more likely to affect someone’s health,” Arber said. “It is 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 partners, including legal partners.”

To assess the impact of the program, Arber and co-authors conducted a retrospective, mixed-methods cohort evaluation study and looked at a sample of 1,139 patients over the age of 18 with housing needs who enrolled in the program between October 2018 and March 2021. the cohort consisted primarily of female, nonwhite, and non-English-speaking MassHealth patients with more chronic conditions and more frequent emergency department use than the general population. The evaluation examined the relationships between patient participation in the program and their use of health services and chronic disease management. He also reviewed patients’ charts for data on housing problems, services, and outcomes, and conducted interviews that included questions about their living conditions, health status, and social support.

Program participation was associated with 2.5 fewer primary care visits and 3.6 fewer outpatient visits per year, including fewer visits to social work, behavioral health, psychiatry, and urgent care. Patients also expressed mental and physical health benefits as a result of moving into new housing, and many felt a closer connection to their clinics and primary care teams, thanks in part to the compassionate guidance they received from housing advocates. Another result is that often the patient’s first housing solution is not stable or healthy, which speaks to the complex scale of the unaffordable housing situation.

“The decrease in outpatient care was mostly due to less urgent care, behavioral health, and social work use, suggesting that the program has important effects on mental health and behavioral health,” Arber said. “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.”

Study limitations include small sample size, short-term follow-up, limited data set, and self-report data. The researchers also acknowledge that the program’s interventions do not address the root causes of housing insecurity and health disparities.

As burnout in primary care is on the rise, the research team plans to examine the effects of the residential program on clinical staff and providers to see if this may also be linked to feeling more supported when dealing with distressing situations with patients.

“Being homeless or at risk of homelessness is incredibly stressful and damaging to mental health,” Arber said. “The most fascinating aspect of the study for me was hearing the patients’ stories and reflections. Not only did they feel that their physical and mental health improved as a result of the program, but they felt a sense of belonging and genuine care for them in a care clinic.”