At Boston Medical Center, 25 percent of patients admitted to the hospital are homeless, and even more live in unsafe places or are at risk of being evicted; conditions that research shows can exacerbate health problems. Children's HealthWatch data from BMC's pediatric Emergency Department shows that one in three families are housing insecure, meaning they have unstable housing or are in jeopardy of eviction.
Boston Medical Center is investing $6.5 million over five years to support a wide range of affordable housing initiatives, in an innovation lab approach that will be studied closely to determine the best ways that health care systems can improve both community and patient level health and reduce medical costs by addressing homelessness and housing insecurity.
In this inspiring segment, Thea James, MD, and Megan Sandel, MD, MPH, discuss a significant new initiative to tackle one of their patients’ most daunting problems; a lack of stable housing.
Thea James, MD & Megan Sandel, MD, MPH
Thea James, MD is an Emergency Room physician as well as Associate Chief Medical Officer and Vice President of Mission at Boston Medical Center. She has primary responsibility for managing BMC’s strategic relationships and partnerships with organizations including community agencies, housing advocates, community mental health providers, and substance use and violence prevention programs. She is also co-founder and director of BMC’s Violence Intervention Advocacy Program (VIAP).
Megan Sandel, MD MPH, a pediatrician and professor at Boston University School of Public Health is a nationally recognized expert on housing and child health. In 1998, she published, with other doctors at Boston Medical Center, DOC4Kids — a national report on how housing affected child health. Over the course of her career, Dr. Sandel has written numerous peer reviewed scientific articles and papers on this subject.
Melanie Cole, MS: One in four patients admitted to the hospital is homeless, and even more live in unsafe places or are at risk for being evicted. Conditions that research shows can exacerbate health problems, Boston Medical Center is embarking on a significant new initiative to tackle one of its patients’ most daunting problems – a lack of stable housing. My guests today are Dr. Megan Sandel – she’s a pediatrician and associate professor of pediatrics in public health at Boston University School of Public Health and she's a nationally recognized expert on housing and child health – and Dr. Thea James – she's an emergency room physician as well as associate chief medical officer and vice president of mission at Boston Medical Center. Welcome to the show. Dr. Sandel, I’d lie to start with you. What's the prevalence of unstable housing among patients? What have you seen?
Dr. Megan Sandel, MD, MPH: One of the things that we noticed is that many of our patients are facing different forms of housing and stability. For some of our patients, they may be homeless or have a history of homeless that places them at risk of becoming homeless in the future. Some of our patients are living in many places during the year, so moving at least twice and really being unstable about where they're sleeping every night. Lastly, we have a whole subset of patients that are falling behind on their rent and having to make really toxic choices between or food or heat or medicine. We estimate one in three of our families face one of those three forms of housing instability that places them at risk of becoming sick.
Melanie: That’s an incredible number that you just quoted. Dr. James, what have studies shown that insecurity, whether it’s food or housing, does to a person’s health?
Dr. Thea James, MD: First of all, lack of social support and foundational things that people need to thrive are directly affected or connected to the health of a person. For example, things like income, educational, level of education – those things actually affect not only your life expectancy but also chronic disease. As Dr. Sandel was saying, sometimes patients have to make really tough or toxic choices if you have to make a decision between being able to pay for your prescriptions or paying a copay for an office visit or paying for transportation to get to a hospital and using your limited resources to feed your family or keep your utilities on or to pay your rent, the decision is quite easy for people. Meanwhile, their disease continues to rage out of control and manifest as repeat emergency department visits and repeat hospital admission and all the other effects that chronic disease unmanaged has on your body over time.
Melanie: Dr. Sandel, tell us a little bit about the initiative through Boston Medical Center.
Dr. Sandel: Boston Medical Center has embarked on a really exciting housing initiative where we're going to be investing in housing partnerships as a way to both improve the health of the community but also potentially help patients be healthier and reduce cost. We've embarked on a lot of different variety of these partnerships, both investing in specific housing developments and how to make them healthier, also in service provider partnerships where we will place new resident services on site as a way to make patients healthier, and then other forms of community engagement, trying to really spur innovation to try and help people be stable in their housing. We’re excited that we’re really leading the nation in these ideas as a way to use housing as a prescription for health.
Melanie: Dr. James, are you following other models? What have they seen in terms of results of an initiative such as this?
Dr. James: There are some other models across the country that have embarked upon investing in communities as a way of providing strategic economic initiatives to create vibrant communities. Other organizations across the country like Dignity Health and Trinity Health, for example, and even Kaiser. We actually formed a network of these hospitals across the country over the past year, like 32 organizations, to form the Healthcare Anchor Network, and one of the reasons that we're forming is to not only disseminate these types of initiatives but also to provide opportunities to learn from each other.
Melanie: Dr. Sandel, since BMC isn't building its own housing units or serving as a landlord, how is this funded?
Dr. Sandel: This initiative is funded through an obligation we have as a hospital for when we redo our campus. The Department of Public Health in Massachusetts asked that we set aside a certain percent of the project for a community health initiative, and so, Dr. James and I approached the Department of Public Health and said we want to put all of this money into a single need that we see in our community, which is the lack of affordable housing and develop this community health initiative as a way to do it. For us, it was a really exciting use of the dollars and it's one that we really see as part of our mission at the institution that we're an anchor in the community. We can use our economic power, in this case, this community health initiative as a way to not only improve and increase the amount of affordable housing, but as Dr. James said, be able to do community development and be able to attract healthier retailers, bring jobs to the community and that really is ultimately about moving upstream. We don’t want to be a sick care system, we don’t want to fix people up, patch them to treat them; they're just going to come back to us. We really want to move upstream and be able to make a better health and better trajectory for people’s lives and we think this investment is going to set us on that path.
Melanie: Dr. James, who qualifies under this initiative?
Dr. James: We won't have direct responsibility or input into exactly who goes into some of these units initially, for example, but through working with the various different community development corporations and other partners, hopefully at some point it may provide us with some opportunities to have some direct pathways, for example, or some preferences at some point, obviously following housing laws, but hopefully it will provide us with some opportunities to have some sort of preferred access to some of the units.
Melanie: Dr. Sandel, as you’re speaking about preventive medicine and how that saves all of us in the long run as the financial model in healthcare does shift to one that rewards providers such as yourselves for helping patients to stay healthy, speak about some of the other factors along these lines and how many providers are taking a new interest in the social factors that are involved in the healthy human as a whole.
Dr. Sandel: I think we are acknowledging more and more that when you look at the predictors of health outcomes, healthcare actually typically only predicts about 10% or 20%. We know that many social and environmental factors like your ability to live in a safe neighborhood, to exercise, to have healthy food, to have healthy jobs and transit are bigger predictors of health. As we have thought as an institution, Boston Medical Center, if we more and more are going to be held accountable for those health outcomes, we have to get outside our four walls. We have to go into the community and find new ways to do these types of investments. For us, this is one way of which we can redefine care that we can start thinking about engaging in these partnerships so that our patients will have access to new beautiful affordable housing or renovated housing that we can start thinking about creating jobs in our community and supporting new businesses through our purchases. I think those are ways in which we think we can make Boston the healthiest urban population in the world is being able to be really intentional about how we apply our economic power. I think that’s something that ultimately will reward us. We are more and more entering into these value-based contracts where we’re going to be held accountable for outcomes. We want to bend the cost curve, we want to be part of the solution to decrease healthcare costs, and so we think this is part of our strategy.
Melanie: Dr. Sandel, sticking with you for a minute, how do you even measure what you're discussing right now? How do you even measure a return on investment?
Dr. Sandel: It’s a great question to ask us about how we return on investment because we are thinking about this initiative first and foremost as a community health initiative, so we are targeting certain communities that are traditionally underserved, our Roxbury and Dorchester neighborhoods in Boston, and our neighborhoods that have the worse health outcomes. What we say is that we are engaging in these partnerships to try and really increase the capacity of our housing partners to be able to serve those communities by having better housing, more housing and also more community developments. That being said, we are entering into accountable care organization contracts with Medicaid here in Massachusetts, so we are starting to think about frameworks in which we have a logic model and we've engaged an evaluator at the Metropolitan area planning council around thinking through the community health benefits, but also our population health outcomes and building our own analytic framework within the hospital where we can say this patient lives in a development where we’re doing an investment, so let's look at their outcomes relative to a similar development where we aren’t making these investments. First and foremost, this is about improving the community, but we’re also trying to understand the business case of this because we think it has a double bottom line. We think this is an investment that can see improving communities, but also improving our healthcare as well.
Melanie: Dr. James, what about community engagement? What are you telling the surrounding community about what you're doing and how they can get involved?
Dr. James: The communities that surround our hospital and the communities particularly where we’re doing this investment, they are a very vocal, very vibrant community, very much engaged in what's going on in their community. They have lots of community meetings and those types of things. For example, they do know about what's going on – it was in the Boston Globe and other local papers – people have called into the hospital to ask about it, someone called here and asked whether or not they thought the hospital was actually giving away money for people to develop housing, but we had to explain that to them, but they wanted to be a part of it. Just this week, the supermarket that’s going to be in the development was introduced to the community and many people showed up to ask various types of questions about what impact the supermarket, not only would it have on the community, but what impact it would have on an existing store in the community and how it might impact the stability of that place; what kinds of foods that it would be bringing in; if it is hiring from the community, are there some people who may not be able to be hired, for example, people who have criminal records and that type of thing – the supermarket was gladly able to tell them that in Washington D.C., they're not even allowed to ask that question.
I would say the community is very much aware, very much engaged and very much excited about the initiative that they're doing. They really like this and I think one of the reasons they like it so much is Boston Medical Center is a safety net hospital, that in it of itself is unusual for us to embark upon something like this, given what our pair mix is and where our margin is and that type of thing, but I also say that we see this new reimbursement model as an opportunity to actually change and alter the life course of the most vulnerable patients in the state. We see this as an opportunity to not just, as Dr. Sandel was saying, filling gaps for people, working downstream and filling gaps, but you actually eliminate the gaps by going upstream and addressing the causes and disparities in health by addressing the root cause. The root causes are all embedded in these different projects we have in the housing initiatives; the housing instability and lack of income and lack of access to affordable foods and employment and that type of thing. It’s a long-winded way of saying that the community is very much engaged and excited about what we’re doing because it’s quite nuanced and new.
Melanie: Dr. Sandel, wrap it up for us. What an amazing initiative and we certainly applaud all the great work that you two ladies are doing on behalf of the Boston Medical Center community. Summarize it all what you would like the listeners to take away from this and what you would like them to know about getting involved in this new initiative.
Dr. Sandel: I think that in many ways this initiative really is consistent with our culture at Boston Medical Center. Sometimes we need to move mountains, and while some people would say why would a hospital do housing partnerships, we are asking why wouldn’t a hospital do housing partnerships. This is a huge problem for our patients. We have to innovate in this space. There's not enough housing. We know it’s making people sick and it’s increasing healthcare costs. This is one way of which we’re trying to really create a path for other hospitals to follow, ways in which we can be able to create better health, and as Dr. James my partner says on this, move upstream away from just sick care to really helping people have better health. We’re excited to work with a lot of other health systems and a lot of other housing partners where this will become the usual care and it won't feel very strange at all; it’ll feel like this is the natural path forward.
Melanie: Thank you so much ladies for all the great work that you're doing. It’s really an amazing initiative. This is Boston Med Talks with Boston Medical Center. For more information on how hospital and housing partnerships can heal communities, you can go to bmc.org. That’s bmc.org. This is Melanie Cole. Thanks so much for listening.