In Chicago, a Regional Funding Pool is Helping the Chronically Homeless Get Off the Street and Into a Permanent Home
A successful demonstration program lays the foundation for a $13 million funding pool for supportive housing.
By Barbara Ray
Joanne was short of breath. It was 2017 and she was homeless, living on the streets in Chicago’s Uptown neighborhood. Joanne (a pseudonym) has bipolar disease and self-medicates with alcohol and crack-cocaine, according to the local alderman, James Cappleman. She’s been arrested at least 18 times and picked up by police far more than that. Joanne is also well-known to the staff at Weiss Hospital in the neighborhood. Cappleman was with Joanne when she became short of breath. A 911 call went in, and within minutes a police car, firetruck, and ambulance pulled up and greeted her by name.
“The EMS driver told me that Joanne had been calling 911 twice a day for the past two years,” Cappleman wrote in an email, “and that there were literally hundreds of Joannes out there in Chicago who do the same thing every day of the week.”
While Joanne may be calling 911 frequently, Eric (also a pseudonym) wants nothing to do with the ER and typically refuses medical care. Eric, too, is homeless, and his health is extremely fragile. He is bipolar, has a serious eye infection with open sores that need attention, and he is addicted to drugs. He has been arrested 25 times. He told Cappleman that he didn’t care if he lived or died.
Homelessness is more than lacking a home. It is a dangerous health condition.
Like many people experiencing chronic homelessness, Eric and Joanne are in fragile physical states. Nationally, people who are chronically homeless living on the street have mortality rates as high as many cancers. A chronically homeless individual can expect to live to only age 52. Homelessness is a health risk at any time, but during the COVID-19 pandemic, it’s an even greater risk. Legislators are looking at ways to better cope with the problem. The Better Health Through Housing demonstration program in Chicago along with a new funding pool to expand the services can offer some guidance. Since November 2015, Better Health Through Housing has worked with four hospitals to house 104 homeless individuals like Joanne and Eric.
“Homelessness is more than lacking a home,” says Stephen Brown, a licensed clinical social worker and director of Preventive Emergency Medicine at the University of Illinois Hospital and Health Sciences System, a public hospital in Chicago and a participant in the Better Health Through Housing pilot. “It is a dangerous health condition.”
“Chronic homelessness is a major social determinant of health,” Brown said. Individuals like Eric and Joanne who are unsheltered and on the streets for sometimes years have health care costs that can be 2.5 to 160 times higher than an average patient at University of Illinois Health systems, he said.
Despite the dire health consequences, for years there was little Chicago hospitals could do to help these vulnerable and often very sick individuals get off the street, out of the ER, and into a safe and stable home. But now, thanks to the success of the Better Health Through Housing pilot, a novel source of funding and a group of cross-sector partnerships have emerged to help some of Chicago’s most needy homeless get off the street.
Organizations Band Together to Create a Flexible Funding Pool
In 2019, Chicago’s two major public hospitals — University of Illinois Health Hospital and Clinics and Cook County Health — along with city and county offices, the Chicago Housing Authority, and several other private-sector and philanthropic organizations, banded together to create a flexible pool of funds to support a comprehensive supportive housing system.
Modeled on a similar funding pool in Los Angeles, the funding pool in Chicago is designed for men and women who are homeless and high users of public crisis services, including emergency rooms. The Flexible Funding Pool helps identify, locate, and — most importantly — house these most vulnerable homeless individuals.
Chicago’s Flexible Housing Pool received approximately $13.4 million for the next three years.
Chicago’s Flexible Housing Pool has received approximately $13.4 million for the next three years. The money funds a monthly housing subsidy and in-depth wraparound support services for homeless individuals who have cycled through three public systems within the last two years: Cook County hospital; the Cook County jail, which daily houses 9,000 inmates, one-third of who report mental illness; and one of any of the city of Chicago’s homeless shelters.
The largest contributors to the Flexible Housing Pool are the City of Chicago and the Chicago Housing Authority, with approximately $10.5 million, followed by Cook County Health and the Blue Cross and Blue Shield Foundation with approximately $2 million invested over the next three years. The remainder comes from Advocate Aurora Health and University of Illinois Hospital and Health Sciences System. Several philanthropies are providing support for planning and early development of the pool. The Corporation for Supportive Housing provides collaboration and project management. The Center for Housing and Health and its subcontractors handle the support services for tenants.
“This Flexible Housing Pool creates the financing to allow these different groups to band together in a way that can move the needle on this hard issue,” said UIC’s Stephen Brown.
The program is in line to house half of the homeless super users the program identified in Cook County Hospital, or about 140 people.
Identifying Homeless in Need
The program begins when a person experiencing homelessness shows up in a hospital’s emergency room, often Cook County hospital. Cook County hospital, the Midwest’s largest public hospital, serves 83 percent of the city’s known single adult homeless population, according to Christine Haley, director of housing at the hospital.
A novel alert system within the electronic health record informs hospital staff if the person has been a persistent user of both the health system and the homeless system in the last two years. In spring 2020, 300 people met that criteria. A social worker then lets the patient know that an apartment awaits if he or she wants to get off the street.
That they are identifying patients by frequency of use across systems, not just in one system, is novel, said Haley. “We’re very excited about this approach,” she said. “It’s these persistent, high-use patients who will most benefit from supportive housing.”
Once the person agrees to join the program, a team at the Center for Housing and Health steps in to locate an apartment. The Center can tap into a network of apartments, mostly privately owned buildings, said Peter Toepfer, the Center’s executive director. When COVID-19 hit, Toepfer said, they added empty hotel rooms to the stock, working to move the most vulnerable into those rooms for the interim, including those in encampments, crowded shelters, and the immunocompromised.
While there are some hurdles, like criminal backgrounds, landlords are typically open to the program, he said, particularly given that the rent subsidy is handled by the Center for Housing and Health. It can take 74 days on average to get a person settled into a permanent apartment, and interim “bridge” housing is provided by nonprofit community development corporations (CDCs), affordable housing developers, or private landlords. “We would be open to more,” Toepfer added.
The Center pays the landlord using the subsidy from the Flexible Housing Pool, and the tenant contributes 30 percent of his or her income, whether from employment or a disability check. If tenants have no source of income, they do not pay rent until they have a secure income. A typical monthly rent is $1,000.
“Responsibility cannot stop at the hospital door with this population. If responsibility stops there, they’re homeless on the other side of the door.”
This emphasis on housing, said Dennis Culhane, the Dana and Andrew Stone Chair in Social Policy at the University of Pennsylvania and a national expert on homelessness, is an important feature. “Responsibility cannot stop at the hospital door with this population. If responsibility stops there, they’re homeless on the other side of the door.”
The referral options for hospitals are limited, and many hospitals turn to medical respite services instead of accumulating the uncompensated costs of excess hospital days among this population, Culhane said. Medical respite services are acute and post-acute medical care for homeless persons who are too ill or frail to recover from a physical illness or injury on the streets but are not ill enough to be in a hospital. But, as Culhane notes, medical respite centers “are not solving the housing problem” — the source of the poor health to begin with.
The Flexible Housing Fund, he said, “is a far better approach” and an important exemplar, particularly as states such as California require hospitals to have a discharge plan for homeless individuals. The California “Dignity in Discharge” law (SB-1152), for example, forbids hospitals from releasing homeless individuals from the ER without a written discharge care plan and a place to go.
Laws like SB-1152 and programs like the Flexible Housing Fund are further impetus for expanding partnerships with nonprofit housing providers and health systems across the country.
Increasingly health systems recognize the strong connection between a safe, stable home and health and are thinking about how to ensure their patients have quality housing. As we’ve written, health systems in Ohio, California, Richmond, VA, and elsewhere are partnering with CDCs and community development financial institutions (CDFIs) to build affordable housing for low-income families in their communities.
Toepfer is hoping that this funding pool can provide an entry point for local health systems to think more deeply and collaboratively about community investment in supportive housing.
“While I don’t think health systems are going to get into the property management business,” said Toepfer, “they are certainly recognizing their role in housing as a social determinant of health.”
Caseworkers — the Lynchpin to Success
In the Chicago program, once an apartment is found, a team of caseworkers from both the Center and Cook County Health ensures that the person is settling in to their new home and getting connected to an array of supports as needed. Community-based caseworkers help set up health care appointments and help the person manage medications. A housing case manager links the person to the appropriate benefits or employment options and helps with budgeting and other issues. If problems arise with the landlord, they act as the go-between.
“In traditional supportive housing you have the case managers and housing management. We’re adding in care coordination support.”
This care coordination is one step beyond what most supportive housing programs offer, said Cook County Hospitals’ Christine Haley. “In traditional supportive housing you have the case managers and housing management. We’re adding in care coordination support.”
In addition, the Cook County staff meets twice a month with the housing specialists and housing case managers to talk about where people are in the housing process and whether they might need additional health or behavioral health supports as they make the move into a permanent home.
“We are continuously communicating with Center to provide the support,” said Haley. “Once they’re housed, we ensure that the housing case manager and care coordinator know each other and are coordinating their efforts.”
Toward Collective Impact
Providing a home is attractive to health systems despite the costs. A recent preliminary study that Build Healthy Places Network supported shows that, nationally, the return on investment on a $90 million community development project generated $351 million in health returns over the life of the project — a 291percent rate of return that accrued to a range of organizations including hospital systems.
At University of Illinois Health system, ER use decreased by 67 percent among Chicago program participants.
When systems are not working in a coordinated way to address needs, people feel like a pinball.
In Chicago, the next stage of the program is to expand beyond the original partners to include such possibilities as EMS, the police, mental health providers, and substance use treatment. With more organizations on board, they can better divert homeless people before they end up in jail or homeless shelters, which for people with serious mental illness is the worst place for them, said UIC’s Stephen Brown.
“It’s really complicated system that is not functional collectively, and we are not moving fast enough,” said Brown. The result, said Toepfer is that people feel like a pinball.
“If we’re not working together in a holistic way with the vulnerable person at the center, then all the systems are failing that person. And we are failing thousands right now.”
“If we’re not working together in a holistic way with the vulnerable person at the center, then all the systems are failing that person. And we are failing thousands right now,” Brown said.
The Flexible Housing Pool’s aim is collective impact, said Haley. “It has enormous potential to bring other eyes and partners to the table.”
Partnerships and coordinated planning will be critical to success, professor Culhane thinks. “You can’t improvise a solution like this.” He recommends that communities have a planning council of hospitals, insurers, homeless providers, community development organizations and CDFIs, all in the room putting together a plan, “because the problem is bigger than any one smaller initiative,” he said.
“There is a will to make it work,” he said. “The misery of living out doors demands it.”
Culhane would also add experts on aging, given the impending crisis of an aging homeless population. By his estimates, the homeless population over age 65 is set to triple by 2030, and their health care costs are consistently higher across the board than the younger homeless population. Getting this population housed, he said, is where managed care can truly save money.
But the needed trust and cooperation to make cross-sector partnerships work don’t happen overnight. It’s complicated, Brown concedes, “but there is a will to make it work,” he said. “The misery of living out doors demands it.”
Toepfer, too, is excited by the tremendous spirit of collaboration around the table. It is gratifying to sit alongside these many people and organizations all working to make a better system, he said. “My most visceral response is a lot of hopefulness. This funding pool is one of the major tools that is helping us advance this cause because if we want to truly end homelessness in our region, then we need a much wider group of people who are willing to stand up and say, ‘we need to do something about this.’”
“My most visceral response is a lot of hopefulness. The Flexible Housing Pool is an important way to stand behind the belief that housing and health care are human rights.”
“People need a home to be healthy, and at the end of the day,” said Toepfer, this Flexible Housing Pool and the housing and supports it provides “is an important way to stand behind the belief that housing and health care are human rights.”