(68) Improving Lives, Saving Money: Housing Solutions for Substance Use Disorders

Background & Introduction: People experiencing homelessness (PEH) and substance use disorders (SUDs) frequently rely on emergency departments (EDs) and withdrawal management (WM) services to receive care (1). High utilization of these services have been associated with the experience of homelessness, which is a barrier to maintaining care and meeting basic needs. Housing First initiatives have been implemented to address the needs of the growing number of PEH in the United States (2). Studies have shown that individual housing placements for PEH with SUDs result in a reduction in ED and WM service utilization over time (3). This case report examines shifts in utilization patterns for three patients who frequently accessed EDs and WM services before securing housing. All patients were part of an intensive case management team for individuals with severe SUDs and high ED and WM utilization. To be eligible for our program, patients must have had 18 combined ED, WM, or inpatient hospitalizations within a six-month period. Each patient was offered housing through a different housing initiative in Denver, Colorado; however, the housing was unrelated to their involvement with our team. We compare admission rates to ED, WM, and inpatient services during equal time periods before and after securing housing.

Case Description: All three patients had been experiencing homelessness for over two years prior to securing housing. Alcohol use disorder (AUD) was the primary SUD for all three patients.
1. Mr. A is a 58-year-old (yo) Native American man with a history of involuntary and voluntary treatment for AUD. He became eligible for housing through a federal Housing Choice voucher. Securing housing was complicated by a felony record, and he moved into housing 11 months after receiving the voucher. Although he was abstinent from substances at the time of move-in (October 2023), he returned to use shortly thereafter. In the year prior to housing, he had eight ED visits, 15 WM visits, and one inpatient hospitalization. In the year after housing, he had 15 ED visits, one WM visit, and zero hospitalizations.
2. Mr. B is a 60-yo Native American man who has never identified alcohol as a problem. He spent several years living in a car or sleeping in a wheelchair on the street. He has a history of involuntary treatment for his SUD but did not voluntarily seek care other than overnight stays in WM. He received housing through a voucher from the Colorado Statewide Supportive Housing Expansion (SWSHE) project. He moved into temporary housing in August 2023, then into an apartment in October 2023. In the year prior to housing, he had 77 ED visits, 30 WM visits, and three inpatient hospitalizations. In the year after housing, he had nine ED visits, zero WM visits, and three hospitalizations.
3. Mr. C is a 67-yo Hispanic and Native American man who has consistently been pre-contemplative about changing his alcohol use. He reported using EDs as a form of shelter. He received housing through a hospital collaboration with the Denver Housing Authority (DHA) to secure housing for patients with frequent hospital visits. He moved into transitional housing in June 2024 and is set to transition to permanent housing through a DHA voucher. In the six months prior to housing, he had 110 ED visits, one WM visit, and seven inpatient hospitalizations. In the six months after housing, he had 12 ED visits, zero WM visits, and one hospitalization.

Conclusion & Discussion: These cases highlight the potential for housing individuals with severe SUDs to reduce healthcare costs through decreased ED, WM, and inpatient visits. Based on limited claims data for the three patients, we calculated average costs per visit: ED ($5,204.29), WM ($1,254.42), and inpatient ($46,099.31). When comparing equal time periods before and after housing, total cost estimates decreased by $27,231.16 for Mr. A, $391,723.32 for Mr. B, and $787,870.70 for Mr. C. Although Mr. A experienced an increase in ED utilization, this was offset by decreases in WM and inpatient visits. For comparison, the annual rent for a one-bedroom apartment in Denver is $19,692. Although federal allocations for housing and healthcare typically come from different sources, these cases suggest that investing in housing could potentially improve the health of vulnerable individuals struggling with SUDs. All three patients are involved with an intensive case management team for individuals with SUDs. While our team is not directly connected to the housing opportunities, our work with patients before, during, and after their transition to housing has been integral to securing and maintaining housing. These successes suggest that Housing First programs with integrated supports focused on SUDs are worth exploring as a public health intervention.

References: 1. Doran, K. M., Rahai, N., McCormack, R. P., Milian, J., Shelley, D., Rotrosen, J., & Gelberg, L. (2018). Substance use and homelessness among emergency department patients. Drug and alcohol dependence, 188, 328-333.
2. Davidson, C., Neighbors, C., Hall, G., Hogue, A., Cho, R., Kutner, B., & Morgenstern, J. (2014). Association of Housing First implementation and key outcomes among homeless persons with problematic substance use. Psychiatric Services, 65(11), 1318-1324.
3. Miller-Archie, S. A., Walters, S. C., Singh, T. P., & Lim, S. (2019). Impact of supportive housing on substance use–related health care utilization among homeless persons who are active substance users. Annals of epidemiology, 32, 1-6.