In an effort to combat the increasing numbers of people experiencing homelessness in Utah, leaders in the continuum discussed options to improve the system at the 2024 Utah State of Reform Health Policy Conference last month.
Tyler Riedesel, housing insecure population epidemiologist at the Utah Department of Health and Human Services (DHHS), said that formal public health agencies have not historically been a part of the conversation around solving homelessness. DHHS wants to be a part of the solution, which resulted in the creation of Riedesel’s position.
It is difficult to get health data for the homeless population for a variety of reasons, Riedesel said. Hospital systems do not have standardized ways of tracking whether or not patients have stable housing.
“There is a lot we don’t know about the health of people experiencing homelessness,” Riedesel said.
Michelle Flynn, executive director at The Road Home, discussed the Homeless Management Information System (HMIS), Utah’s statewide data tracking system. HMIS allows people working in the homelessness space to see the state’s data in one place.
“The challenge is a lot of the data—and all the data around health—is self-reported at intake and very minimal,” Flynn said. “And this lack of data has really hampered our ability to talk about the health needs of the population, and seek the assistance we need. We know we need that data.”
DHHS is working with Intermountain Health and the University of Utah Health to improve the way hospitals track the health of the homeless population, Riedesel said. He added that the agency wants to ensure hospitals are part of the conversation, rather than being mandated to meet a certain requirement, so they can find solutions that work for their systems.
The state has also begun tracking a “homeless or not” variable for all deaths that occur in Utah, and DHHS will release a mortality report for deaths among the homeless population soon, Riedesel said.
Janida Emerson, CEO of Fourth Street Clinic, said stable housing is a vital aspect of healthcare. She referenced a common saying in the homelessness space; “Housing is healthcare, and healthcare is housing.”
Unhoused individuals often end up utilizing the healthcare system more than others, Emerson said.
“There are a lot of different places that our patients are hitting the healthcare system, [which is] having an impact on health outcomes, healthcare utilization, and ultimately healthcare costs.”
— Emerson
Emerson discussed a man who was in a hospital due to frostbite because he did not have stable housing. The man had to get some of his toes amputated, and needed intravenous (IV) antibiotics. He could not be discharged because he had no place to go, as shelters do not allow people on IV antibiotics to stay in them.
Fourth Street Clinic utilizes motels for unhoused individuals, but there are no healthcare personnel on staff to ensure an IV antibiotic is being administered correctly, Emerson said. The man had to stay in the hospital longer than necessary because there were no discharge options for him, Emerson said, which ultimately cost more money.
Closed-loop communication can be difficult when providing healthcare to people without stable housing, Emerson added. Without closed-loop communication, there are diagnostic, referral, and treatment delays that have negative impacts on health outcomes. Chronic diseases are also especially difficult to manage.
“If you think about that in the setting of a homeless health center where maybe you have some critical labs that you need to run on an individual but that individual doesn’t have a phone, you don’t know how you’re going to be able to find them,” Emerson said.
Fourth Street Clinic’s staff has become creative when trying to contact patients, Emerson said. Sometimes staffers venture out on the streets to find the individual they are looking for.
Riedesel also emphasized housing as a healthcare intervention. He said he sees many programs and initiatives for behavioral health services for the homeless population—which are important—but it can be difficult to focus on an individual’s behavioral health when they are unsure where they might sleep that night.
“If I took your guys’ coat away and put you outside, would you guys be thinking about your appointment with your psychologist this afternoon? Or would you be thinking ‘I need to find a coat? I need to find a place to stay. I need to get warm.’”
— Riedesel
Once an individual’s basic need of stable housing is met, other health issues can be addressed because things like follow-up (care) and medication management are easier to administer, Riedesel said.
Flynn said the homeless population’s needs vary significantly. People could be experiencing homelessness for the first time because they could not afford rent, or they may be experiencing chronic homelessness or intergenerational poverty. She emphasized the importance of building services for all these different experiences. People must be able to access these services after they find stable housing as well.
“We don’t want people to stay in a shelter or stay homeless because they have a connection with a support that they’re afraid they’re not going to get once they’re in housing,” Flynn said.
In order to build robust services, organizations and agencies supporting the homeless population need funding, Flynn said.
“Every funding source that we have in the homelessness services field is a competitive application. It’s either private grants, (or) it’s an annual grant request to a city, county, state, or federal government for all the different pieces, and we have to weave all of those funding sources together and make it work.”
— Flynn
While Gov. Spencer Cox recommended significant funding for affordable housing and homelessness services in his proposed budget ($193 million for alleviating homelessness, $45.5 million for affordable housing, and $150 million for the Utah First Homes Program), the version approved by the legislature only allocates $41 million for those services.
Moving forward, hospitals/mental health hospitals and correctional facilities need to find ways to be a part of the solution and ensure people who are discharged from these facilities don’t have to live on the streets or in temporary shelters.
Emerson said a reimbursement model for the homelessness care continuum is needed. She also wants to see more support for clinicians who want to enter community-based healthcare settings because, in reality, private practice clinicians make more money and are able to pay back their student loans more quickly.
“We have to think about our future generation of both clinical staff and our supportive staff, and think about how we’re exposing them to community health settings to make them get excited about being in that environment,” Emerson said.
Flynn would like to ensure there are additional housing services for the aging population, as many older Utahns are living off social security and can be priced out of rent due to their fixed income. She also wants to make sure there are services available to fill healthcare gaps for people who aren’t covered by Medicaid.
“How can we look at what the needs are, identify what we can do or what we hope to do, but also be very clear about what the other resources are to help fill those gaps?” Flynn asked. “Because there are always these gaps that Medicaid doesn’t touch.”