Homelessness cannot end when we don’t find a way for different systems to work together seamlessly. This becomes apparent when we examine the importance of improving the connections between healthcare and housing sectors to address homelessness.
Homelessness is extremely unhealthy, and in many cases lethal. According to the National Health Care for the Homeless Council, which is headquartered in Nashville, as well as other research organizations, the life expectancy of people experiencing long-term homelessness is at least 15-20 years shorter than that of the general population.
Even though this is a known fact, it is still an uphill battle in many places for the health and homelessness sectors to work closely together. Hospitals nationwide struggle with the question of how to discharge people without a home to go to where they can recover. In the most extreme cases, we hear of stories where people are released to the streets in their hospital gowns in the middle of the night and show up in front of a local shelter, which is often not equipped for recuperative care.
During the height of the COVID pandemic, I coordinated with hospital case managers on appropriate discharge locations for people experiencing homelessness who needed to recover and isolate but were not sick enough to remain in the hospital. The city of Nashville implemented a plan to provide isolation beds. But those beds are no longer available and recuperative care and/or medical respite beds offered by nonprofits are still underfunded.
A recent case study published by Community Solutions and the Institute for Healthcare Improvement explored the approach of a nonprofit systems change agency called Journey Home, which serves the Greater Hartford area in Connecticut. Journey Home recently hired a homeless medical liaison within their homeless response system. When an individual experiencing homelessness is identified within a hospital, this liaison position serves as a point of contact to help hospital case managers refer people to housing navigation and other support services. Connecticut hopes to build that needed bridge between the health care and housing systems.
In 2015, Nashville attempted to create a multi-system collaboration effort called Hospital to Home. We even hired a Metro staff position as a liaison. The endeavor failed because we lacked a solid and functional homelessness data system, which is necessary to support coordination of housing services. Pivoting, we shifted our focus to building our local Homeless Management Information System (HMIS) as well as creating a functional coordinated entry process within the homelessness response system. Once those tools were in place, the COVID pandemic hit, which actually provided a blueprint of how the different sectors can successfully collaborate.
Unfortunately, some of the Metro leadership did not focus on lessons learned in the homelessness arena and returned back into their departmental lanes or, as I would call it, to a status quo, reactionary focus to gain quick political wins in regard to homelessness.
Yet, with a new, well-staffed Office of Homelessness in place now that works under the Mayor’s Office and with the upcoming administration change, I have hope that the strategic focus can shift quickly to long-term, sustainable solutions. In real terms that would mean that an incoming mayor can strengthen cross-departmental collaboration and explore how Metro can help convene needed community partners to improve access to housing and health care for people experiencing homelessness and create sustainable solutions.
“Partnerships don’t just happen,” wrote Stuart M. Butler and Marcella Maguire for the Brookings Institution in a 2022 article. “They need ‘connective tissue’ — an infrastructure supporting frequent and systemic level collaborations — to help form the partnership and hold it together over time.”
If we want to truly make a difference in ending chronic homelessness and ensuring we have a system that is capable of assisting people with access to housing quickly, we cannot continue to be mostly reactive. Thus, the new Metro leadership has to find a balance between being reactive to current emergency needs (which in homelessness are always present) and sustainable solutions that include the identification and creation of permanent housing opportunities combined with long-term support services.
In actuality, the federal, state, and local governments know what to do and where to invest to ensure people’s health and housing needs are met. However, keeping sectors separated allows for minimal, short-term investments in band aid solutions that result in quick political wins. Building a sustainable approach that links different systems comes with a hefty, long-term investment plan that may pay off in 10-20 years big time for a community.
At this point, band aids don’t stick anymore, and we cannot afford at the local levels to wait until the necessary fundamental policy changes at the national and state levels are implemented to permanently end homelessness. Thus, the following areas are starting points for the incoming administration in Nashville to consider:
- Explore the coordination between the different sectors starting with the examination and improvement of how the different Metro departments and committees dealing with health, homelessness, and housing issues coordinate their services to the most vulnerable neighbors.
- Convene health providers and hospital leaders to develop a private funding mechanism to support medical and recuperative care beds for people experiencing homelessness.
- Create coordination positions that are hard to fund in the private and nonprofit sectors to focus on cross-sector collaboration across systems. Start by looking at Connecticut’s homeless medical liaison and the process they implement to link the hospital and homelessness sectors.
- Improve communication and transparency because effective collaboration is built on trusting relationships where people working in different sectors feel heard and see themselves as equal partners.
Finally, engage the Homeless Planning Council and other relevant Metro boards to understand each others’ area of expertise, and educate them to properly oversee and support Metro employees to become the best public servants they can be. The Metro oversight structure needs to provide accountability and ensure we continue to focus on systems improvement and filling needed gaps through community wide engagement.
Finally, the new administration must truly endorse Housing First by actually implementing evidence-based practices.
With the right leaders building trust and helping guide the local efforts, Nashville is in a good position for a cross-sector effort that not only reduces homelessness for some of the most vulnerable of our neighbors but also helps the bottom line of our local health system, especially hospitals.
After all, we cannot forget that people who are able to maintain their health are housed. Or in other words, housing is a fundamental part of health care.
To read about a new private sector collaboration that focuses on linking health care and housing for people experiencing homelessness, read our Q&A about the proposed Vanderbilt Homeless Health Services.