Today’s focus on revenue streams, value-based payments and the needs of people who use multiple services creates one of two false paradigms. Either we try to fit the square peg of supported housing into the round hole of clinical interventions, or we reduce housing to merely a roof over one’s head. Neither appropriately captures what supported housing is, what it accomplishes or the way we implement it in New York City.
New York City’s tens of thousands of units of supported housing are exceptionally diverse: single site and scatter site, living alone or with roommates, single use or mixed used buildings, tens of units or hundreds of units, and the nature and frequency of services spanning the gamut. In all of these instances, the people we serve succeed both because they have a roof, AND because having a roof opens opportunities for receiving individualized services, for engaging in collective activities and for becoming part of a wider community.
True supported housing builds a home, frequently through a messy, complicated process with multiple fits and starts. In order to do it well, continually improve how it’s done, and secure funding for it, we desperately need to get clear on how we describe just what it is. Supported housing is, at its most basic—stability and shelter. But those two components do not come close to describing the full picture. The additional services that help people to stay in housing and make it a home are highly individualized and difficult to measure, which is why assigning a value to this “product” is so difficult.
The most attractive (to funders) and easily reimbursed interventions are those to which we can attach a Medicaid billing code and a clinical outcome. At SUS, we’ve had difficulty locating the billing code that corresponds to the weekend barbecue – even though after that, one of the building’s residents finally started meeting with a case manager to go grocery shopping. The clinical outcome associated with helping set up a study space in an individual’s room was very difficult to describe – but there was a big party when this person got her GED.
We are still far from a consensus on what “value” means in housing and are still counting and reporting on those things we try to prevent, like hospitalizations and incarceration, rather than those things we try to promote like employment, independence and recovery. Indeed, A1C levels and fewer emergency room visits do tell us a part of the story, but we need new colors and new paint brushes to truly paint the full picture that depicts the energy, time and resources that go into creating homes and community.
Activities that promote social connection, that give a person a purpose, and aid in recovery are at the base of delivering supported housing. We know the detrimental health effects of social isolation and we implement the kinds of recovery-oriented, peer-supported collective activities that promote health and wellbeing. Yet, we still have few ways to measure them. Adopting one of the fledgling measures for happiness, or community integration is a good start.
The isolated measure of medication adherence, for example, disregards the community of the building: staff, the people who live there, the people who visit, the people who do business there and nearby, the activities and shared meals and support; and it also discounts the way our buildings and the people who live and work there impact the greater neighborhood. We know supported housing raises surrounding property values. It’s time to measure how our well planned, well integrated buildings increase the health of the surrounding communities.
Engaging the people we serve in collecting these measures will ensure we get it right. They tell us how to define success. They know what to value. And, they know it is about much more than how many “units” are filled. We need to listen more closely, and then hear, understand and incorporate the fact that success has to do with how people feel when they wake up in the morning and go to sleep at night in their own beds in their own homes and what they do in between.
The future of housing services depends on a number of factors: the commitment of government to support capital costs – while a roof is not the sole necessity for success, it is a critical component; the ability to provide intense support services, e.g., case management, on-site psychiatry, etc. to manage transitions and complex cases; and the support for stabilizing activities which promote health through community, purpose and leisure time well spent. Perhaps most importantly in these times, our future mostly depends on our ability to define, measure and describe our success in ways that include what it is to live a rich, full, purposeful life AND with all the requisite data our funders need and deserve.