UTHealth Science Center at Houston

‘Stand Up’ to Homelessness: A Person-Centered Coordinated Care Solution Highly Ranked

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UTHealth Science Center at Houston

Houston, Texas, United States

http://www.uth.edu

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To learn more about – or provide significant funding to – this project, please contact Lever for Change.

Project Summary

Homelessness comes at extreme individual and societal costs—many individuals experiencing homelessness suffer from debilitating conditions, while communities struggle to create integrated systems that address their complex needs, leading to the misallocated use of costly services.The University of Texas Health Science Center at Houston (UTHealth), National Health Care for the Homeless Council, The Salvation Army, and US Department of Veterans Affairs (VA) National Center on Homelessness among Veterans will partner to scale the VA’s evidence-based coordinated care solution for veterans experiencing homelessness (Homeless Patient Aligned Care Teams [H-PACT]) to all individuals experiencing homelessness across seven US cities (~25,000 individuals). We will integrate services into a one-stop-shop tailored by the local community to simultaneously address needs of this vulnerable population (e.g., healthcare) while transcending enumerable barriers.Our solution will improve the health and housing of individuals experiencing homelessness, reducing the financial and humanitarian burden of homelessness on communities in the US.

Problem Statement

Even by conservative estimates, over 500,000 people in the US experience homelessness each night, including 1 in 10 young adults (18-25 years). Homelessness is caused by an intricate interplay between structural factors (e.g., systemic racism), systems failures, and unmet individual needs. In the US, untreated behavioral and physical health conditions are consistently ranked as a primary cause of homelessness, and homelessness itself can quickly lead to otherwise preventable chronic health problems. Without healthcare, there are critical delays in treatment, overuse and misuse of emergency services, preventable hospitalizations, and early death. Mismanaged mental health needs further drain societal resources leading to the overuse of law enforcement and the justice system, financially straining under-resourced communities and causing traumatic stressors for individuals and their families. While safety nets exist, current delivery models require navigating a complicated system with fragmented healthcare services. Without a solid infrastructure to facilitate system navigation, homeless service providers and healthcare providers often operate in silos driven by separate but complementary mission-specific outcomes. Further compounding the problem, people experiencing homelessness have limited resources and low social support, lack transportation, and have multiple competing behavioral and physical health needs that can make barriers insurmountable. Many people cannot meet all of their daily needs, forcing them to choose between taking medications, visiting a provider, or securing enough food and a place to stay. The emotional drain of navigating complex systems leads to hopelessness and perpetuates homelessness. As a result, many services available are underutilized by those who need them the most.

Solution Overview

The VA has invested billions researching homelessness and is the top US integrated care provider. In 2012, the VA developed H-PACT, a homeless service solution that provides co-located person-centered healthcare, housing, and social services. It has improved housing and health outcomes for veterans experiencing homelessness and saved $5 million annually in emergencies and hospitalizations. Extending the success of this innovative evidence-based solution, we will scale H-PACT to all individuals experiencing homelessness. To remove barriers to access, H-PACT will be delivered through mobile sites modeled after the VA ‘Stand Down’ events where diverse service providers are brought together in accessible locations (e.g., parks). In our scaled version (called Stand Up), we will provide the infrastructure and technical assistance to coordinate and extend existing services (e.g., healthcare, mental health, social services) facilitated by a mobile unit. Stand Up units will bring services to individuals directly by co-locating coordinated multi-disciplinary teams in a one-stop-shop including providing IDs, showers, a mobile healthcare clinic, and 5-6 ‘service navigation stations’ (e.g., housing, benefits) to simultaneously address priority needs. Stand Up will be tailored to align with the needs/strengths of the local community. Data sharing and predictive analytics will enhance care coordination. We will implement Stand Up across seven US cities (~25,000 individuals), kickstarting a movement to redefine homeless service delivery. As with H-PACT, Stand Up will increase service utilization/satisfaction, healthcare utilization, and housing access among individuals experiencing homelessness, with subsequent reductions in societal costs (e.g., hospital use); making it an effective, efficient, and sustainable service solution.

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