These actions are informed by four months of primary and secondary research conducted by our team. Our team analyzed national best practices and global innovations as well as the policies, organizational structures, regulatory authorities, and performance reports of local stakeholder agencies to understand the systems-level structures that drive performance. We consulted with more than 100 local and national public officials, system administrators, and technical experts to understand the challenges and opportunities at hand.

Our ability to develop these actions also required an understanding of the current state of services derived from the experiences of frontline staff and people experiencing homelessness. Our research team leveraged a mix of design workshops, interviews, and site visits across King County. Our lines of inquiry identified the most pressing challenges for accessing and delivering services and the dynamics between service providers, customers, and the system.

Read about our methodology and process

There are not adequate health services to support safe and stable exits from living outside for people experiencing chronic unsheltered homelessness. There have been many behavioral health improvements and innovations in King County, however, the lack of targeted care for people experiencing homelessness is a significant barrier.

While the majority of people experiencing homelessness do not suffer from substance use disorder or psychotic spectrum illnesses, they make up a disproportionate number of people currently living outside. Due to the nature of the crisis they are facing, the needs of this population are often acute and debilitating. Any attempt to directly incorporate them into existing behavioral health services would likely tax providers and destabilize the system.

Because of this, Action 7 is to expand physical and behavioral health options for people experiencing homelessness.

To appropriately respond, it is necessary to develop resources tailored to the needs of this population. These will require the deployment of new service models and the activation of different funding models from both the federal and state levels, as opposed to the repurposing of existing system components, which are already performing vital functions for other vulnerable populations.

Our research with customers¹ and providers identified two main areas of health-related need among those experiencing homelessness. First, health needs (both physical and behavioral) are difficult to prioritize for customers who find themselves in ‘crisis mode.’ Their ability to sort out their degree of need is compromised by the complexity of their situation, the stress associated with finding ways to navigate unfamiliar service systems, feelings of isolation, and (often) the need to care for the basic needs of others (children or family). Second, continuity of care is particularly challenging within service systems that typically don’t address co-occurrence of health needs (e.g., substance use and mental health), or basic access challenges (such as transportation and coordination among providers). In addition, lack of familiarity with health services and care coordination among staff providers creates a piecemeal and reactive approach to addressing the health needs of customers. Finally, many health services are staffed by inexperienced providers whose tenure is frequently very brief, which results in inconsistent quality of care.

Based on the 2018 King County point-in-time (PIT) count, 27.3% of respondents identified themselves as having a chronic health problem or medical condition, 34.6% as living with “drug or alcohol abuse”, 43.9% as living with a psychiatric or emotional condition, and 36.5% identified as living with PTSD. 8.8% of survey respondents (approximately 1,000 people) believed that “mental health issues” were the primary event or condition that lead to their homelessness.²

Given the reality that many people are not captured by even the most well executed PIT count, it is reasonable to operate under the assumption that the need for behavioral health supports is greater than what is reported here. This represents a large population in need of services, particularly services that are capable of responding to high levels of acuity. People living with serious mental health conditions who are also forced to reside outside often have complicated physical health needs in addition to their behavioral health needs. Managing these simultaneously is often too difficult for standard health providers, and is attempted only to the detriment of the patient. Creating programs that have the capacity to meet customers needs will require a focus on the development of innovative models of clinical support, some strategies for which can be found below.

However, those models will only function if they are embedded with providers who have the capacity to manage them. While some providers may be able to scale quickly into providing robust physical and behavioral health services to people experiencing homelessness, others will need assistance. Overall, there is a need to have a secure pipeline of clinicians skilled at providing the kind of support necessary. Therefore, several strategies below focus on increasing the capacity of providers.

Focus on the development of innovative models of clinical support.

1. Invest in holistic care communities.

Holistic care communities are housing models that incorporate Assertive Community Treatment (ACT), a customer-involved and multidisciplinary team casework model, to provide comprehensive community-based psychiatric treatment. The model focuses on rehabilitation and support for people living with serious mental health conditions, substance use disorders, and histories of incarceration. Holistic care communities provide patients with community support, medication, education, empowerment, and complementary treatment to meet each person’s medical, social, psychological and spiritual needs.¹ Holistic care communities are made up of employed caseworkers and patients who live together and build support networks that can address each individual’s personal, social, and environmental needs.² The goal is to equip customers to transition into the community-at-large should they express the desire to do so.

Holistic care communities and the broad practice of ACT are effective in addressing behavioral health needs for people experiencing homelessness.³ A comprehensive review of ACT models showed a 37%⁴ greater reduction in homelessness and a 26% greater improvement in psychiatric symptom severity than traditional casework.⁵ Further studies showed that ACT significantly reduces hospitalization⁶ and improved treatment outcomes for both housed patients and those who are experiencing homelessness. While not a substitute for appropriate medical intervention, ACT significantly decreases the necessity for psychiatric or medical evaluation as well as expensive medicines for patients.⁷ Instead of managing behavioral health through emergency rooms and clinics at heavy cost, ACT is a community-centered, lower-cost alternative that can be tailored to people experiencing homelessness.

2. Implement shared decision making.

In order for medical and non-medical services to both meet the clinical needs and preserve the dignity and independence of people experiencing homelessness, Shared Decision Making (SDM) should be implemented across service streams. SDM is a clinical model where providers and patients work to reach decisions around care plans together.⁸ SDM training is not exclusive to clinical decisions; it should also be integrated into the training frameworks of caseworkers and other staff who will engage in decision making roles with customers. 

SDM improves the quality of medical consultation, treatment decisions, patient-physician communication, and satisfaction of both patients and physicians in clinical practice.⁹ SDM improves patient health outcomes by removing anxiety in interactions and increasing compliance with treatment regimens. These approaches are especially good at increasing successful outcomes for vulnerable populations. Decision aids, or peer support, improved SDM consultation outcomes even more by increasing patient knowledge, reducing decisional conflict, and increasing patient involvement.¹⁰ SDM as an interdisciplinary casework and medical tool increases equity and impact disparities in housing, medicine, and behavioral health. Clinical research found that with SDM, homeless women felt “empowered” and their input increased intervention success.¹¹

3. Expand employment of peer supports in behavioral health care programs.

In workshops and interviews, customers shared the positive role of lived experience peer supports. Peer support workers are “experientially credentialed”¹² by their own recovery journey, and as such are not trained as clinicians or more technically credentialed. However, the Washington State Health Care Authority does train and qualify mental health consumers as certified peer counselors,¹³ which allows peer workers to provide Medicaid prevention services at behavioral health agencies, which is billable under Medicaid.¹⁴

Peer support workers have been shown to be especially helpful in supporting people with mental health conditions, substance use disorders, and those with co-occurring disorders. Peer support workers who have been successful in their own recovery process are in an ideal position to share practical guidance, help people develop their own goals, and take concrete steps towards building stable lives for themselves.

Many of the struggles customers shared with regards to experiencing homelessness are well-addressed by peer supports: reducing isolation, easing integration into permanent housing, and improving social skills. Peer supports are also especially successful in improving outcomes for drug and alcohol treatment, mental and physical health, and social support.¹⁵ Structured relationships with peer supports have been shown to reduce hospital admissions rates, decrease psychotic symptoms, and decrease substance use and depression.¹⁶ As an empowering, strengths-based approach, drawing on peer support is also effective in increasing people’s sense that their treatment is responsive and inclusive of their needs,¹⁷ increasing engagement in self-care and wellness,¹⁸ and increasing social support and functioning.¹⁹

The Substance Abuse and Mental Health Services Administration (SAMSHA) has outlined core competencies for peer supports. These core competencies require that services are recovery-oriented, centered on the person participating in services, voluntary, and trauma-informed.²⁰

In order to better meet customers’ socio-emotional needs, which are inextricably connected to their physical and mental health, the city and county should leverage Medicaid reimbursability to embed peer supports in all mental health and substance use disorder recovery services for people experiencing homelessness, scaling the number of peers based on the number of individuals enrolled in the program. Following recruitment, peers should be engaged in ongoing training in the core competencies listed above. These identified competencies should inform salary structures, certification standards and job descriptions. Supervisors and workers themselves should also use these competencies to assess job performance.

This opportunity to provide effective, culturally-competent care to behavioral health customers is also an opportunity to develop a robust employment pipeline for people experiencing homelessness who have been successful in their own recovery.

4. Establish access to harm reduction approaches system-wide.

Harm reduction policies consist of a wide range of ways to limit the negative social and/or physical consequences related to human behaviors within and outside the law. Harm reduction should be targeted specifically to prevent permanent consequences from behaviors related to substance use disorder or other behavioral health conditions. Relevant examples of effective harm reduction services include: needle distribution and recovery programs; substitution therapies for heroin with legally prescribed opioids; take-home naloxone programs to reverse overdoses; supervised consumption facilities in encampments not designated as sober; education on lower levels of consumption; and peer support programs. Increasing the availability of needle exchange programs and broader harm reduction initiatives incentivizes safer substance use, which reduces lethality and infection.²¹

In un-housed communities, harm reduction strategies have the ability to reduce hepatitis,²² HIV,²³ overdose deaths, early deaths among those who use substances,²⁴ IV drug use in public places, the number of used needles in public, the sharing of needles,²⁵ emergency department visits,²⁶ substance use frequency, and crime. Harm reduction strategies increase employment among those who use substances, education, and successful referrals to treatment programs and health and social services. Additionally, harm reduction can be enhanced with peer supports, trauma-informed care,²⁷ and co-planning to give agency to people experiencing homeless.

Research on needle exchange programs in the United States verifies that they are cost efficient inhibitors of HIV transmission²⁸ and increase substance user access to social, medical, and behavioral support services.²⁹ A mobile needle exchange contributes to decreases in emergency room visits; in the case of Yale New Haven Hospital it helped lower ER visits 20% in a year.³⁰ Safe injection spaces increase enrollment in detoxification treatment and are not correlated with social disruption to their communities.³¹ Housing first programs which provide services regardless of an individual's substance use habits reduce medical costs, social care costs, housing costs and alcohol use³² while improving clinical outcomes for those living with HIV/AIDS.³³

5. Expand access to medication-assisted treatment (MAT) for people experiencing homelessness who are struggling with opioid use.

Though most people experiencing homelessness do not have opioid use disorders, there is an overrepresentation of people struggling with opioid misuse among those experiencing homelessness. Overdoses in King County disproportionately affect people experiencing homelessness: 1% of the population in King County is experiencing homelessness, but 14% of all drug and alcohol deaths were people presumed to be experiencing homelessness.³⁴ The region must expand access to medication-assisted treatment and make treatment accessible for those living outside, in shelter, and in housing programs in order to reduce the rate of fatalities and the prevalence of opioid use disorders among those experiencing homelessness—and in order to prevent people from returning to homelessness due to opioid misuse.³⁵ MAT treatment has been identified by SAMHSA to:

• Improve patient survival.
• Increase retention in treatment.
• Decrease illicit opioid use and other criminal activity among people with substance use disorders.
• Increase patients’ ability to gain and maintain employment.
• Improve birth outcomes among women who have substance use disorders and are pregnant.
• Increase housing stability for people experiencing homelessness.³⁶

Medication-assisted treatment (MAT) is defined as the use of FDA-approved medications, paired with behavioral therapies and counseling, to treat substance use disorders and prevent overdoses. The National Institutes of Health asserts that MAT decreases behavioral inpatient readmission³⁷ and increases rates of survival among patients with substance use disorders,³⁸ retention in treatment,³⁹ and housing stability for people experiencing homelessness.⁴⁰

In the Seattle and King County region, MAT clinics specifically tailored to the needs of people experiencing homelessness are limited. The region can work with state and federal partners to leverage public funding to expand access to treatment for people who are struggling with opioid misuse and experiencing homelessness in the region. This work can be undertaken by:

• Assessing the prevalence of opioid use disorders and opioid misuse among individuals experiencing homelessness.
• Developing and implementing overdose prevention and response strategies system-wide, including in encampments, shelters, and in permanent and transitional housing programs.
• Strengthening partnerships between housing and health care providers to provide assistance in facilitating connections between services and housing when applicable.
• Expanding access to medication-assisted treatment by scaling the services already available in the region, increasing the number of providers who are able to prescribe these medications, and pairing these services with behavioral therapies and counseling.
• Removing barriers to housing for those in treatment by ensuring that landlords and providers do not misunderstand these medications to indicate ongoing drug use.

Shelter-Based MAT with Buprenorphine exhibits the benefits of Office-Based Opioid Treatment while limiting systemic barriers of child care needs, stigma, and travel distance.⁴¹ Shelter-Based MAT is flexible, portable, can be instituted long-term, and is effective for treating people experiencing homelessness comparable to housed patients.⁴² If properly controlled for shelter stay lengths that facilitate phased treatment timelines, Shelter-Based Suboxone MAT can be instituted to effectively deliver MAT and combat alcohol and drug addiction. According to DEA regulations, the process to initiate Shelter-Based Suboxone MAT requires a Federally Qualified Health Center (FQHC) to obtain a waiver from the county Department of Public Health. DEA regulations require referrals to happen only within the qualified shelter organization, thus incentivizing a centralized FQHC body across the county to be embedded into shelters.⁴³

There is opportunity to expand MAT in King County. In a 2015 Washington State Medication Assisted Treatment report, areas served by MAT clinics in King County saw positive 80.7% change in publicly funded opioid treatment admissions between 2003 and 2015, and 21.1% change in deaths attributed to opioids.⁴⁴ Still, access is limited. Substance Abuse Prevention and Treatment Block Grants as well as SAMHSA funding for free treatment referral services and new certified MAT treatments can improve regional capacity to rehabilitate people who experience homelessness and addiction co-occurrence.

For refutation of myths that surround MAT please refer to The National Council Challenging the Myths pamphlet.⁴⁵ The National Institute on Drug Abuse also offers a general model⁴⁶ and tools⁴⁷ for implementing MAT.

Focus on increasing the capacity of providers.

1. Launch a homelessness specific residency program with a longitudinal integrated clerkship model.

Given the density of hospitals and medical providers in King County, and particularly Seattle, a new regional authority on homelessness could work to foster relationships with residency programs to a launch homelessness specific residency program via a longitudinal integrated clerkship (LIC). LICs are a model of clinical education where medical and psychiatric school residents follow a set of homelessness patients across the homelessness system, build relationships in the community, and administer care.⁴⁸ A homelessness specific LIC would open new pathways to quality, targeted care for people experiencing homelessness and monitoring and evaluation of the homelessness system.⁴⁹ In this framework, residents, working as both a health system navigator and an arm of primary care, would be assigned specific patients experiencing homelessness. Partnerships with local universities would mobilize available resources and integrate residents to better understand lived-experiences of homelessness.

Homelessness specific residency programs leverage medical residents to facilitate comprehensive care for patients experiencing homelessness over time. Learning relationships between residents and patients are effective in producing successful primary care outcomes at lower resource cost. While typical medical services are often short-term and overly focused on inpatient clinical experiences, such clerkships incentivize a holistic patient-centered focus on outpatient and inpatient needs.⁵⁰ For example, the Tufts Maine Track model for rural health, pairs residents with a rural community in the state of Maine and is tightly interwoven in community health efforts. Retention of graduating physicians was high. 64% of the graduating class of this LIC program stayed in Maine after completion, many even returning to the same rural community. Patients treated by Maine Track graduates note that graduates understand their cultural context, liveliness concerns, and are more likely to be effective in shared decision making (as described above).^{51 52}

Designating certain residents to directly address the needs of people experiencing homelessness builds critical capacity and increases the overall skill level available within healthcare systems to manage the high levels of acuity that many people experiencing chronic homelessness present within medical settings. Increased community clinic abilities lower emergency room admittance and saves significant tax-payer dollars.⁵³ More importantly, LIC students show heightened understandings of social determinants of illness and recovery and exhibit increased commitment to patients.⁵⁴

Instead of only treating symptoms that result from homelessness, LIC students are longitudinally trained to uncover much deeper and complex understandings of homelessness lived experience in order to wholly address its complications. LIC students follow patients over time through different care venues, shelter-based health clinics, ER visits, psychiatric hospitalization, surgical treatments for medical complications, detoxification, and addiction treatment. In the event that a customer obtains permanent supportive housing or some other permanent housing option, clinicians learn to adapt to new patient realities and reorient care to the new customer goals, such as the stabilization of chronic conditions like substance use, HIV, or depression.⁵⁵

2. Colocate services and braid funding streams.

Creating innovative programs at scale to serve the needs of customers will require fostering and investing in partnerships across provider networks rather than funding individual providers. In order to effectively address co-occurrence of serious mental health conditions, substance use disorders, and serious physical health needs, fully integrated clinics should be prioritized for funding. This should include incentives for mental health, substance use, and medical clinics to be colocated using a collaborative applicant model (as exemplified by the HUD CoC application process). As evidenced by customer voice in workshops and interviews, people experiencing homelessness with significant health needs find themselves juggling time between noncontinuous health offerings. Individuals experiencing homelessness see non-specific and scattered healthcare as a barrier to accessing effective care.

It is also possible, through innovative partnerships between shelters and HRSA Federally Qualified Health Centers (FQHCs) to leverage reimbursement frameworks that allow for customers to engage in meaningful psychiatric, behavioral, and medical treatment while they are temporarily housed in a shelter context. Additionally, FQHC frameworks allow for the treatment delivered to be culturally relevant to the customer. This makes possible the development of reimbursable programs that are specific to historically marginalized populations, which are overrepresented in the population experiencing homelessness (e.g. Native, black, or LGBTQI people).

This model, which has proven extremely effective at Central City Concern (CCC) in Portland, Oregon, incorporates ACT with housing and other services as an FQHC. By leveraging their status as an FQHC, all health services that CCC provides, including culturally holistic non-medical treatments, are billable to Medicaid. A recent study done by Portland State University found a 95% reduction in the use of illegal drugs among participants and a 93% reduction in criminal activities among program participants. Central City Concern also contributed significant financial returns to the city. Before treatment, the 87 people cost the city roughly $2 million dollars in policing and processing their criminal activity, and $6.5 million dollars in emergency room visits, policing, and substance use treatment in one year. In the year after the Central City Concern intervention, the city saved a collective $5,729,750 on those 87 individuals alone. All services were billable to Medicaid or directly subsidized.⁵⁶

3. Leverage the Medicaid Transformation initiatives and reimbursement processes to expand access to long-term services and supports

The Medicaid Transformation transition to Integrated Managed Care (integrated physical and behavioral health services), away from just acute care, begins under the Managed Care Organizations in January 2019.

In order to facilitate sustainable long-term services, King County should capitalize on 1) the mandate under the Accountable Communities of Health initiative of the Medicaid Transformation waiver (detailed below) to design and scale integrated care delivery models, including bi-directional integration of behavioral health and community health clinics; 2) the March 2018 amendment to the waiver that covers expanded access to inpatient and residential services for individuals with substance use disorders; and 3) the mandate under the Foundational Community Supports initiative to cover more behavioral health, long-term care, and employment support services.

It is especially important to leverage the reimbursement framework for Foundational Community Supports, as it specifically enables supports for accessing and maintaining housing and obtaining and keeping a job under the same framework. The connection between housing and economic instability is described in Action 4, as is the importance of providing integrated quality supports that simultaneously address a person’s stated health, housing, and healthcare needs. The scope of this mandate is expected to expand with the transition to more integrated care systems overall. This must be capitalized on for people experiencing homelessness.