The Montefiore Health System Addresses Housing as a Social Determinant of Health in the Bronx
From its beginnings in the Bronx more than a century ago, the Montefiore Health System has grown to become one of the nation’s largest, with 11 member hospitals and more than 180 specialty and primary care locations in the Bronx and the lower Hudson Valley. In 1950, the New York hospital system was the first in the country to establish a department of social medicine, demonstrating an early understanding of the link between patients’ social and economic condition and their health. In the 1980s, Montefiore took a step toward addressing housing, a major social determinant of health, by forming the Mosholu Preservation Corporation and becoming an affordable housing provider in the Bronx neighborhood of Norwood. Montefiore’s commitment to housing stability as a social determinant of health has continued in the new millennium with the establishment of interventions, including the Housing at Risk program, to identify and assist homeless and housing-insecure patients.
The Housing at Risk Program
In 2009, the Montefiore Health System launched the Housing at Risk program to connect patients at its three Bronx campuses with housing resources. The housing program features an alert system that identifies housing-insecure patients upon intake at the emergency department, admission to the hospital, or discharge. A patient’s file can be automatically flagged based on factors associated with homelessness — for example, if they list a shelter as their home address, do not provide an address, or are being seen by a doctor who primarily works with patients experiencing homelessness. But some individuals may not trigger an alert because they are couch surfing, living with relatives, or facing eviction, explains program director Deirdre Sekulic. Referrals by nurses, case managers, social workers, and outpatient clinicians bridge the gap for those who are not automatically identified. The preventative aspect of the program is important because Montefiore staff often see patients who may be in danger of losing their housing during the course of their treatment; the population of individuals actually experiencing homelessness is smaller in the Bronx than in some other New York City boroughs. The alert system produces hundreds of alerts per year, with 3,600 alerts recorded between 2009 and 2016.
In the next step of the Housing at Risk program, the patient is assigned to one of 27 full-time hospital social workers for an evaluation to clarify the housing problem, followed by case management to resolve it. The social worker’s goal is to connect the patient with resources that can help them locate stable housing. “If they’re unsheltered, we get them into a shelter; if they’re in a shelter, we help them get into transitional housing, and so on,” explains Sekulic. The social workers also help patients with tasks related to getting or keeping housing, such as accessing legal counsel, obtaining vital documents and records, and applying for benefits. This work includes coordination with the patient’s doctors to ensure that the patient’s housing situation is conducive to receiving medical care. In 2017, the most recent year for which data are available, the housing program provided case management for 123 patients.
The Housing at Risk program also works closely with New York City’s Department of Homeless Services (DHS), often helping patients living in the DHS shelter system obtain transfers or other accommodations to facilitate medical care. “We might have somebody who’s getting chemo or dialysis here in the Bronx, but they’re staying in a shelter on Long Island. We can work with DHS to get them a spot in a shelter closer to their doctors,” says Sekulic.
Despite the best efforts of Housing at Risk program staff, sometimes a homeless patient must be discharged from the hospital before a more stable housing arrangement can be made for them. When patients cannot be discharged into the DHS shelter system because of their medical needs, Montefiore places them in a respite care center run by Comunilife, a longstanding housing and social services provider in New York City. Montefiore currently rents four beds in the respite center, having increased the count from the two it began renting in 2012. The respite center does not provide clinical staff, but patients can be treated in the center if they have been assigned a home health worker for medical assistance, such as physical therapy or help with a feeding tube or other device. The average stay is 90 days, but patient stays can exceed the 8-week limit, explains Sekulic, who also oversees the respite program, “especially if we know that they’re about to get into a more permanent housing situation.” In 2017, Montefiore’s respite beds served 20 patients.
Other Housing Assistance
In addition to the Housing at Risk program, Montefiore participates in two significant housing organizations that address affordable housing and other social determinants of health in the Bronx. The Bronx Health and Housing Consortium, which Montefiore helped create in 2011, is a collaboration of more than 70 hospital systems, managed care organizations, government agencies, and housing providers. The consortium’s goal is to improve access to health care and housing for Bronx residents. In addition to educational events hosted by Montefiore, the consortium holds a quarterly housing marketplace where member organizations discuss their clients’ needs and the available resources to address those needs. The consortium also holds regular interagency case conferences during which attendees collaborate on difficult and complex cases. In addition, each year the consortium surveys people experiencing homelessness who visit Bronx emergency departments. This survey takes place on the same night as the annual DHS Point-in-Time count of unsheltered individuals on the streets and uses the same survey instrument in order to provide a more complete picture of homelessness in the Bronx.
The Mosholu Preservation Corporation is a nonprofit community development corporation founded by Montefiore in 1981. Initially launched to renovate and stabilize five apartment buildings obtained by the health system, today Mosholu operates affordable housing units in the buildings and elsewhere in the Bronx. Mosholu also supports small businesses, encourages the development of additional affordable housing, and strengthens community ties in the Bronx. The corporation pursues these goals by managing the Jerome Gun Hill Business Improvement District, publishing the biweekly hyperlocal newspaper Norwood News, and enacting beautification and public safety campaigns in the neighborhood. As of summer 2019, Mosholu owned 112 housing units in the Bronx and additional units in the city of Newburgh, which is home to one of the Montefiore St. Luke’s Cornwall Hospital campuses. According to Jennifer Tausig, Mosholu’s director, the corporation’s board is considering new ways to invest in the health of its neighborhoods as Montefiore continues to identify the issues that most adversely affect each geographic region it serves.
By applying hospital resources to the social determinants of health, Montefiore is seeing positive results in patient outcomes, staff morale, and costs. Although measuring the outcomes of the Housing at Risk program is difficult because of changes in medical recordkeeping since 2009 as well as the inherent complexity of long-term patient relationships, the hospital has collected evidence of the program’s efficacy. Since adopting the housing program, Sekulic reports that Montefiore’s Bronx locations have seen a decrease in repeated emergency room visits, fewer unnecessary admissions from the emergency room, shorter inpatient stays, and fewer readmissions. The housing program has also benefited staff, who now feel more empowered to improve their patients’ lives. When the program began, Sekulic states, doctors and nurses were reluctant to ask about patients’ housing situations because they felt unable to intervene. As the success of the housing program became apparent, clinical staff gained confidence in their ability to meaningfully improve the situations of patients with housing problems. To keep the housing program at the forefront of employee consciousness and maintain its encouraging effect, Sekulic’s staff regularly update clinicians on the status of the patients they referred. In addition, Sekulic estimates a return on investment of at least 300 percent for the Housing at Risk program in 2018, due mainly to reduced readmissions and shortened hospital stays.