Bridging Housing and Health Care to Help Some of Virginia’s Most Vulnerable Residents Get Well
A transformative high-touch, “housing first” approach to supporting people who struggle with chronic homelessness and mental and physical health challenges is getting a kick-start from a collaboration between LISC and Sentara Healthcare in Hampton Roads, VA. One year since the launch of the partnership, its programs are driving health and wellness in the region through investments ranging from small business support to innovative health and housing initiatives—proof of the power of teaming up with local anchor institutions to create real change.
Donna Hufnagle, a social worker with Virginia Supportive Housing (VSH), is on a mission to provide a safety net for a dozen people whose lives, through some combination of housing instability, behavioral health problems, and physical illness, are in freefall. It’s a full-time job that takes Hufnagle all over the Hampton Roads region of southeastern Virginia, where the program is based, and often finds her on the phone with local landlords trying to secure shelter for her clients. Putting a roof over their heads is her first order of business.
In the meantime, she provides “wraparound” services to her clients. One is a woman who is surviving on the streets in Newport News; another is a man who currently bunks at a shelter in downtown Norfolk. One of her clients is couch surfing, another living in her car. Hufnagle meets them wherever they are. People who have no place to land, she knows from experience, “need boots-on-the-ground people—not someone who just calls them up and says, ‘Hey by the way, these services are available.’”
Since tackling homelessness is at the center of this intensive effort, some might be surprised to learn that a health care organization plays a key role. The initiative is supported by a joint effort to improve social determinants of health in underserved communities of Virginia by Sentara Healthcare, an integrated hospital system headquartered in Norfolk; its managed-care subsidiary, Optima Health; and LISC.
Collaborations with medical providers and insurers are hardly unusual for LISC. In 2017, LISC made it a priority to bridge the disparate worlds of health care and community development in order to more effectively address the root causes of poor (and often grossly inequitable) community health outcomes. LISC initiatives with health care partners have flourished in places from Phoenix, AZ, to Cincinnati and Toledo, OH, to New York City.
Sentara’s commitment was in fact instrumental in bringing LISC to Hampton Roads. LISC opened a new office in this seven-city region in 2020, in part to drive the partnership’s programs and investments. Deploying resources from a variety of sources, LISC Hampton Roads has since supported a host of activities that ultimately promote health and wellness for local people, including financial and employment coaching, small BIPOC-owned businesses, and what VSH refers to as its “familiar faces” program.
It’s called that because of its focus on a distinct group of people who tend to make heavy use of inpatient and emergency departments, but without healthy outcomes to show for it—single adults experiencing severe housing instability or homelessness along with behavioral health issues.
Sentara and Optima refer patients to the program. The LISC-Sentara partnership’s grant fund pays for a full-time case manager (Hufnagle), participants’ rent subsidies for up to two years, and household supplies.
“We at Sentara recognize that social determinants of health have a significant impact on our patients’ overall health and quality of life,” explains Sherry Norquist, MSN, RN and Sentara’s director of Community Engagement and Impact. “The extension of care we provide in community settings is far more likely to advance our mission to improve health every day when our patients also have a safe, stable place to live and access to services delivered in the community. Our work with Virginia Supportive Housing aims to support the well-being of some of our most vulnerable patients and helps us to best utilize Sentara’s clinical resources during this pandemic.”
Perseverance pays off
The project brings together two major sectors—health care and housing—that have long operated in silos using different verbiage, funding streams, and referral systems. Not unexpectedly, there have been growing pains and bugs to work out.
Though the familiar faces program technically launched in early 2021, it didn’t enroll its first participant until May. To recruit patients the group was using a technical platform, Unite Us, that was accessible to a broad coordinated-care network, resulting in a deluge of referrals for supportive housing, an in-demand service in short supply.
The pandemic, moreover, has made it far more difficult than usual to get through the program’s next step—obtaining housing for participants. Lacking the requisite 12 vacant units in its own buildings, VSH has used a scattered-site approach, working with private landlords who offer affordable market-rate rentals. But during the Covid-19 emergency there have been precious few apartments available across the Hampton Roads region, as people stayed put for safety and an eviction moratorium reduced turnover to nil through the summer.
“We have a list of about 120 landlords that we work with,” says Jennifer Tiller, VSH director of client programs. “So typically it’s relatively easy to find units, because we’ve established strong relationships and connections with many of those and work with them on a regular basis. With the additional obstacles of the pandemic, after exhausting our list, we had to start canvassing and reaching out. We’ve been establishing new relationships, which is great. It’s definitely picking up a little bit.”
By autumn 2021, some participants had new digs and were receiving Hufnagle’s high-touch case management. And their lives were beginning to change.
Beginning anew
One client, a 39-year-old trans woman, had been on the street for a few years, during which she was frequently exposed to exploitation and harm in her quest for shelter. HIV-positive and a cancer survivor, she lost connections to primary care and access to lifesaving medication. Her health spiraled. When Hufnagle met her, she was suffering from an untreated syphilis outbreak with lesions “from head to toe.”
But in October, thanks to Hufnagle’s coordinating, she moved into her own little place in Norfolk, not far from the beach, where she loves to walk. Hufnagle helped her get into regular care and back on medication, and to undergo a needed surgery. Now she’s talking with the client about starting mental health counseling, and returning to designing and sewing drag costumes, her joy and talent.
Hufnagle in her home office
Another participant, a 66-year-old woman, had lived with her mother and never been homeless in her life—until her mom died. With limited mobility and mental health issues that made it difficult for her to cope, she spent down her money on a hotel, then began a period of couch surfing, petrified of staying in a shelter and embarrassed to reach out for help. After a few months of this, in October, Hufnagle found her an apartment she decorated with beloved family objects that help her feel her mother’s comforting presence. Now Hufnagle is focused on helping her make it to medical and other appointments, and think about work she could do to earn a little money from home—like selling the fine blankets she sews for local neonatal intensive care units.
With the VSH program still ramping up, it’s too early to evaluate overall outcomes. But the partners have reason to expect that this approach will help stabilize the lives and health of participants, while at the same time making more efficient use of health care resources.
For one thing, the supportive housing model rests on a strong evidence base that suggests it improves lives and, resource-intensive though it is, actually reduces costs to a variety of public systems by stemming the cycle that brings people who are chronically unhoused into crisis and contact with emergency and inpatient departments, shelters, rehab and detox centers, and the criminal justice system.
What’s more, VSH has mounted a similar effort in Richmond, now in its third year and showing impressive results. Working with Virginia Commonwealth University Health, VSH rehoused 10 patients—five with sickle cell disease, which can cause recurrent pain crises, and five requiring complex care—in studio apartments in VSH’s New Clay House, with site-based services. In just the first ten months of the program, total patient costs to the hospital system dropped by 37 percent, largely on the strength of reduced inpatient visits and lengths of stay.
Sustaining a strong model
The collaborations with health care organizations help VSH demonstrate “proof of concept—that these programs work,” says VSH executive director Allison Bogdanovic. Yet she points out that health systems don’t tend to see their role as paying patient rents indefinitely—and that points to a sustainability issue that’s a perennial challenge for providers of supportive housing. Many of the people who benefit from this support will need it on an ongoing basis.
The housing side is typically subsidized by U.S. Department of Housing and Urban Development (HUD) rental assistance, and where appropriate VSH will work with Sentara participants to help them transition to a HUD voucher, though these aren’t easy to come by. The services side, a critical piece, is subject to even more inconsistent and constrained funding.
Here, recognizing the impact of supportive services on health and health care costs, the Medicaid program, which provides health coverage to millions of economically disadvantaged Americans, is increasingly stepping up. LISC, through its advocacy and technical assistance, has worked hard to leverage Medicaid funding streams to sustain community-based work addressing such health issues as disproportionate rates of asthma and diabetes. Through a separate $50,000 grant to VSH, LISC is helping the supportive housing organization bring more of those reliable public resources to Hampton Roads.
Specifically, the grant from LISC’s national resources has allowed VSH to prepare an application to provide Medicaid-billable mental health skill building to qualified tenants in its properties. This service overlaps substantially with the coaching and counseling that VSH already provides without dedicated support, helping people in a very individualized way with everything from managing medication to budgeting to keeping their apartments clean to making positive social connections. Likewise, this summer Virginia’s Medicaid program is set to begin an initiative covering housing and employment services—supports that VSH offers as core programming.
VSH embraces the Housing First philosophy, which holds that, for those experiencing homelessness, getting a place to live isn’t the end of a healing process but a beginning, the safer ground on which people may gather the strength to recover, grow, work, connect, make their own choices, and maintain better health.
These results can be described in statistical studies, but also by the simple observation Hufnagle makes when she visits her costume-designing client and notes how much stronger she looks after just two months in her apartment. “When you take an individual off the street and put them into housing,” says Hufnagle, “the transformation is just amazing.”