Screening and Connecting Patients to Safe and Stable Housing: Housing is Health Program Expanded

It is well established that housing is one of the most significant social determinants of health. Safe, affordable, and stable housing is also the most complex and expensive social resource to navigate and secure for patients. In collaboration with Milwaukee County Housing Services (MCHS) and IMPACT Coordinated Entry, the Milwaukee Health Care Partnership (MHCP) Housing is Health program has been screening and connecting homeless and vulnerably housed emergency department and hospital inpatients served at Milwaukee health systems to housing support since 2019. This includes helping patients access temporary housing, providing case management, and aiding in an ultimate transition to permanent housing stability.

“With several thousand men, women, and children in Milwaukee County considered homeless or unstably housed at any point in time, it is critical to create pathways to sustainable housing and supportive services,” said Emily Whitcomb, a Community Intervention Specialist with MCHS. “Health care has an important role to play, particularly in the screening of patients and in creating these linkages.”

The Housing is Health program was initially designed to serve hospital patients with the goal of improving health outcomes post discharge, reducing lengths-of-stay, and preventing inpatient and ER readmissions.  In 2020, the program expanded to serve patients and families at Children’s Midtown primary care clinic. After experiencing positive results, the program was further extended into primary care clinics located in low-income, underserved neighborhoods. As of spring 2022, Bread of Healing Clinic and all five Milwaukee Federally Qualified Health Centers have begun to offer this critical service to their patients.

“Housing navigation services in the primary care setting have been extremely successful in helping keep patients and their families permanently housed and improving health care outcomes,” said Jacqueline Whelan, Manager, Health Management Operations at Children’s Wisconsin. “The continuity of the relationship and trust built in a primary care medical home is a critical piece to assessing and addressing housing barriers for families.”

As of January 2022, Housing is Health has connected 242 patients to temporary housing and facilitated permanent housing for 120 patients across inpatient, emergency department, and primary care settings.

MHCP members are also tracking other community-wide efforts underway to increase safe, secure, and affordable housing stock for low-income individuals and families.  The MHCP has commissioned a study, in collaboration with MCHS, to understand gaps in medical respite housing and ensure clinically appropriate and timely discharges, especially for patients with mental health or substance use disorders.

Funding for the Housing is Health Program is provided by the MHCP health systems’ Shared Community Investment Fund, the Green Bay Packers Foundation, the Greater Milwaukee Business Foundation on Health, the Medical Society of Milwaukee County, and the United Way of Greater Milwaukee & Waukesha County.

Learn more about the Housing is Health Program here.