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Health and Housing: An Overview of the Literature

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Author: Heather Wallace, Erin Georgen, and Elizabeth Swenson
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Better Health Together supports housing-first approaches to solving homelessness. We understand that safe and affordable shelter is fundamental to achieving health equity.

The Housing First approach (Heading Home, 2021) prioritizes establishing access to decent, safe, and permanent housing for people experiencing homelessness to ensure the needed stability for improving health, reducing harmful behaviors, and increasing income. Housing is prioritized, but ongoing support and community integration are crucial to success.

The core principles of this framework are that people must have immediate access to permanent housing without housing readiness requirements, the right to some choice and self-determination over where they live and what support they receive, access to recovery orientation that provides them individualized support, and community integration.

 

Within this model, people in need have:

  • Immediate access to permanent housing without housing readiness requirements

  • Self-determination over where they live
    and what support they receive

  • Individualized support for recovery orientation and community integration

What makes us healthy? A Pie chart shows 40% of our health is based on social-economic factors, 30% is behavior, 10% is bases on our physical environment, and only 20% of people's health is a result of health care.

Health Impacts of Housing Instability

Stable Housing

Providing stable housing over temporary housing services is vital because of the related health benefits that go along with it. Stable housing ensures a secure, predictable place of their own without restrictions on family makeup, pets, or access to visitors. It also ensures a place to cook and store food, access the Internet, and an address to send/receive mail. Often, homeless services do not provide these types of stability resources for those who need them. Studies have shown that all people need access to stable housing in order to decrease their risk of poor health and health outcomes, especially in the case of young people. Some of these outcomes include the increased risk of teen pregnancy, early drug use, and depression.

Unstable Housing

In contrast, the stress of unstable housing disrupts employment, access to social service benefits, and community (Desmond, 2016), (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services, n.d.). Chronic stress and trauma related to housing insecurity, financial stress, and lack of safety impact the mental health of adults and children (Cutts, et al., 2011). Low-income children who switch schools or residences frequently due to housing instability or homelessness had lower math and reading achievement over time and were less likely to graduate from high school. Residency mobility is a better predictor for children dropping out of school than school mobility or living in poverty. (Voight, Shinn, & Nation, 2012)

Supportive Stable Housing Improves Social Determinants of Health

Quality and Safety

Housing conditions are safe and healthy. Beyond just stability, housing conditions must also be safe and healthy as poor housing conditions can increase healthcare costs and contribute to rehospitalizations (Laphear, Kahn, & Berger, 2001). Environmental and safety issues inside homes such as lead, water leaks, poor ventilation, mold, dirty carpets, and pest infestation all increase health risks for both children and adults. Particularly among elderly populations, exposure to high or low temperatures are correlated with adverse health events, including cardiovascular events. A study showed that children from families In federal programs providing home heating or cooling were at a healthier weight and at less of a nutritional risk than those who were not in the program (Taylor, 2018).

Affordability

Covering monthly housing costs consistently leaves enough discretionary spending. Those who are burdened by rent or housing costs have less discretionary income to spend on healthy food, medical care, medications, which can negatively impact health. They also have less to spend on education, which may allow them to increase their wages and build social mobility. In New York City, families with affordable rent payments were able to increase their discretionary spending by 77% (Taylor, 2018). In Spokane County, approximately 31% of households are rent burdened, meaning they are paying 30% or more of income on housing costs (Federal Reserve Bank of St. Louis, 2022).

  • 40% of American renters (19 million households) are cost-burdened with rent, paying more than 30% of income on housing costs (United States Census Bureau, 2022).

  • 18.8 million households were “severely cost-burdened” meaning that they spent more than 50 percent of their income on housing, with much of this burden falling on renters rather than owners.

A lack of affordable housing negatively impacts mental health. The psychological impact of poverty, financial stress, and housing insecurity can increase cortisol and other stress hormone levels. This also affects physical health, as it impacts the health of the heart, digestive, sleep, and other brain functions. (Carrere, Vásquez-Vera, Pérez-Luna, Novoa, & Borrell, 2022)

Residual-income Approach to Measuring Housing Affordability

Accurately understanding the housing cost burdens of each family is essential to determining the scope of housing needs and ensuring that families can afford other nondiscretionary costs, but defining affordability in terms of a percentage of household income creates challenges. The conventional measure of affordable housing (30% of household income) may underestimate the number of households who are burdened by combined housing and transportation costs as well as the number of households in need of quality affordable housing. (Office of Policy Development and Research, 2017)

The residual income approach starts by identifying key categories of essential spending. This includes food, health care, transportation, child care, and a small allowance for other necessary expenses, such as clothing and household goods. This measure incorporates estimates of income taxes owed and tax credits received. This approach recognizes that the necessary basic level of consumption for a household differs according to the number and type of people living in a given household. For example, households with large numbers of young children often have higher costs for health care, food, and child care. The estimated cost of these necessities is subtracted from a household’s income. This calculation produces the amount (and percent) of income that the household members can consistently spend on housing and still have enough left over to cover other necessities. If households spend more on housing than the residual income approach indicates is feasible, they may cut back spending on other essential items. (Herbert & McCue, 2018)

Community

Location facilitates access to social, economic, and health resources. Community impacts health and well-being. Ease of access to a job, grocery stores with nutritious foods, and safe spaces to exercise. Segregation, crime, and social capital also have an impact on a community’s stability (Taylor, 2018).

Benefits of Supportive Stable Housing

Reduces Health Care Costs and Redirects Health Spending

  • Housing First Models show improved physical and behavioral health, reduced healthcare costs, and an average net cost offset of $29,000 per person/year for people in stable housing (Taylor, 2018)

Healthcare costs for people experiencing homelessness or in unstable housing are significantly higher than for those with stable housing. Chronic homelessness leads to higher morbidity of physical and mental health, higher mortality rates, and increased risk of trauma. The costs are most prevalent for urgent outpatient care. Housing insecurity is associated with poor health, lower weight, and developmental risk among young
children, which can increase the cost burden of health care over the course of a person’s life (Cutts, et al., 2011).

Access to affordable housing reduces healthcare costs and moves spending from emergency care to primary care for more efficient resource use and overall cost savings (Taylor, 2018). Providing stable housing decreases Medicaid expenditures and emergency room use.

Reduces Criminal-Legal System Involvement

The relationship between homelessness and criminal justice involvement is bi-directional. Being homeless increases the likelihood of criminal legal involvement, and entanglement with the legal system increases the likelihood of a person becoming homeless or experiencing housing insecurity (Augustine & Kushel, 2022). Formerly incarcerated people in the United States are almost ten times more likely than the general public to experience homelessness (Couloute, 2018). This is influenced by many policies and structures in place that make finding long-term housing post-incarceration incredibly difficult. Many people with criminal records face barriers that block them from affordable housing programs, and certain parole and probation association conditions block people from accepting stable housing options with family or friends, even when the family or friend is willing to house them. Criminal record screening policies and stigma trigger stereotypes and discrimination in the rental process, making it less likely that people with criminal records will be considered for tenancy (Evans, Blount-Hill, & Cubellis, 2012).

In the other direction, homelessness increases the likelihood of contact with police and recidivism, making it a risk factor for reincarceration, violations of supervision, and failure to appear. “Anti-homeless” or “Quality of life” policies increase the likelihood that basic survival behaviors of those without housing, such as sleeping, sitting, or lying in certain public places, are criminalized (O’Brien, Farrell, & Welsh, 2019). Criminal and civil punishment of behaviors related to homelessness serves no constructive purpose. Arrests and unaffordable fines make it more difficult for people to regain stable housing. (Tars, 2021)

Improves Psychological Wellness

Why does having a stable, safe, affordable community to call home matter? The conception of “home” is often defined within four separate categories: the environmental psychology it brings about, how it provides for people with their hierarchy of needs, how it builds attachment and memory, and how it supports a sense of identity or community.

Environmental psychologists documented the qualities that homes expose people to, such as noise levels, toxins, emotional climates, and crowding (or its absence). These factors impact all aspects of people’s living experience, from the personal (biological, cognitive, emotional, behavioral) to the social. Stable housing also provides for individuals’ hierarchy of needs, including shelter, nutrition, hygiene, safety, work, and play, as well as their interpersonal needs for contact, communication, companionship, and belonging. This belonging is also initiated by the third category, attachment and memory. Home, for many, is where they forge and nourish human attachment bonds. “Home” also includes primary locations where early memories and emotions result in attachment scripts and their consequences. Finally, “home” is a place where people build and shape their identity and sense of self. Home is a context for imagining possible selves and expressing personal identity. It is a place to practice boundaries, connections, and communication. Home is a physical and metaphorical place where small groups develop and people express and implement values. (Tower, 2021)

Works Cited

1.

Augustine, D., & Kushel, M. (2022, September 14). Community Supervision, Housing Insecurity, and Homelessness. The ANNALS of the American Academy of Political and Social Science, 701(1), 152-171.

2.

Carrere, J., Vásquez-Vera, H., Pérez-Luna, A., Novoa, A. M., & Borrell, C. (2022, April). Housing Insecurity and Mental Health: the Effect of Housing Tenure and the Coexistence of Life Insecurities. J Urban Health, 99(2), 268-276. Retrieved from www.ncbi.nlm.nih.gov.

3.

Couloute, L. (2018). Nowhere to Go: Homelessness among formerly incarcerated people. Prison Policy Initiative. Nothhampton, MA: Prison Policy Initiative.

4.

Cutts, D. B., Meyers, A. F., Black, M. M., Casey, P. H., Chilton, M., Cook, J. T., . . . Frank, D. A. (2011). US Housing Insecurity and the Health of Very Young Children. American Journal of Public Health, 101, 1508-1514.

5.

Desmond, M. (2016). Evicted: Poverty and Profit in the American City. New York: Crown.

6.

Evans, D. N., Blount-Hill, K.-L., & Cubellis, M. A. (2012). Examining housing discrimination across race, gender and felony history, Housing Studies. Housing Studies, 34(5), 761-778.

7.

Federal Reserve Bank of St. Louis. (2022, December 8). Burdened Households (5-year estimate) in Spokane County, WA. Retrieved 2023, from FRED: https://fred.stlouisfed.org/series/DP04ACS053063

8.

Heading Home. (2021, February 16). Housing First Model: An Evidence Based Approach to Ending Homelessness. Retrieved 2023, from Heading Home: https://www.headinghomeinc.org/housing-first-model/

9.

Herbert, C., & McCue, D. (2018, September 26). Is There a Better Way to Measure Housing Affordability?. Retrieved 2023, from Joint Center for Housing Studies: https://www.jchs.harvard.edu/blog/is-there-a-better-way-to-measure-housing-affordability

10.

Laphear, B., Kahn, R., & Berger, O. (2001). Residential exposures to asthma in U.S. children. Pediatrics, 107(3), 505-511.

11.

O’Brien, D. T., Farrell, C., & Welsh, B. C. (2019, May). Broken (windows) theory: A meta-analysis of the evidence for the pathways from neighborhood disorder to resident health outcomes and behaviors. Social science & medicine(228), 272-292.

12.

Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. (n.d.). Housing Instability. Retrieved 2023, from Healthy People 2030: https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/housing-instability

13.

Office of Policy Development and Research. (2017, August 14). Defining Housing Affordability. Retrieved 2023, from HUD User: https://www.huduser.gov/portal/pdredge/pdr-edge-featd-article-081417.html

14.

Tars, E. S. (2021). Criminalization of Homelessness. Retrieved February 2024, from National Low Income Housing Coalition: https://nlihc.org/sites/default/files/AG-2021/06-08_Criminalization-of-Homelessness.pdf

15.

Taylor, L. A. (2018). Housing and Health: An Overview of the Literature. Retrieved 2023, from Health Affairs: https://www.healthaffairs.org/do/10.1377/hpb20180313.396577/

16.

Tower, R. B. (2021, November 4). The Meaning of “Home”: Four approaches to studying “home” show how home affects our experiences. (Sussex Publishers, LLC) Retrieved 2023, from Psychology Today: https://www.psychologytoday.com/us/blog/life-refracted/202111/the-meaning-home

17.

United States Census Bureau. (2022, December 8). More Than 19 Million Renters Burdened by Housing Costs. Retrieved 2023, from United States Census Bureau: https://www.census.gov/newsroom/press-releases/2022/renters-burdened-by-housing-costs.html#:~:text=DEC.,by%20the%20U.S.%20Census%20Bureau.

18.

Voight, A., Shinn, M., & Nation, M. (2012, December 1). The Longitudinal Effects of Residential Mobility on the Academic Achievement of Urban Elementary and Middle School Students. Sage Journal, 41(9), 385–392.

Funding Opportunity: Grant Writing Stipends for Community-based Organizations

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Updated: October 2, 2024

Allocated 2024 funds have been expended. Please watch for updates in 2025.

Background

If you have been around BHT for a while, you may know we are currently working under a recently renewed Medicaid Waiver 1115, which we are calling Waiver 2.0. One of the key elements of Medicaid Waiver 2.0 is building a robust system of community-based care coordination through the region’s Accountable Communities of Health (hey, that’s us!). Because BHT is made up of partners, board, and staff members who are tenacious problem solvers, we’re starting to build our strategy.

In BHT’s Strategic Plan we’ve grounded ourselves in a 1-5 year view of the following: 

  • Expanding community-based organizations’ ability to connect people to anti-racist care 

  • Shifting power to impacted communities* to dismantle white dominant systems 

  • Improving linkages between clinical and social-care resources 

  • Improving economic and social well-being of the community-based workforce**

We know that capacity building is challenging, and we are developing strategies to support these efforts with a focus on organizations providing community-based care coordination. We are calling this the Community of Learning.

Grant Writing Support Initiative

Overview

It’s important for us to use data to inform our Community of Learning strategy. We started with voluntary Organizational Capacity Assessments for our current community-based care coordination partners, Community Resiliency and Community Linkages partners (two of our funding opportunities from last year), and our broader partner community to understand current strengths and areas for potential investment.

The need for grant writing support emerged as a common, high-priority theme. As a result, we have allocated up to $220,000 to this initiative. Organizations are eligible for up to $5,000 to fund grant-writing technical assistance provided by a grant writing consultant of their choice. Our objective is to support as many community-based organizations as possible to secure additional funding and increase their capacity through these Grant Writing Stipends.

Program Details

  • To request funds, organizations must identify a specific grant opportunity that they want to pursue or have already applied for in 2024 and list it in their application (link below). This can include private or public funding (local, state, or federal).

  • An eligibility check is included as part of the application process to ensure organizations meet the requirements for the identified grant.

  • Funds will be awarded based on meeting the eligibility requirements outlined below.

  • The $5,000 maximum is an organization-level cap, but each specific funding request must go through the application and approval process. That is, if you want to use these funds to pursue two different opportunities, each request must be submitted and approved separately.

  • Funding is not available to spend on grant research or prospecting.

Funding Eligibility

Applicants must be nonprofits or fiscally sponsored organizations located in the BHT region (map at this link) and must meet at least 3 out of the following 4 to be eligible for grant writing support funding:   

  1. Your organization does not have a full-time development director or grant writer on staff (we aren’t counting contracted – so if you have a contracted development or grant support person helping you, you can still apply). 

  2. Your organization has an annual operating budget of less than $2 million. 

  3. Your organization has a current or developing relationship with BHT. This includes organizations that have contracted with BHT at any time, current BHT Collaborative or Forum Members with signed agreements, and/or organizations with representatives currently serving on a BHT technical council or board.  

  4. Your organization has at least 50% representation of folks from impacted communities* on your board or leadership (self-defined leadership).

Additionally, your organization’s mission and values should align with BHT’s Vision, Goals, and Commitment to Anti-racism. BHT’s vision is an integrated and anti-racist health system accountable for better health for ALL in Eastern Washington. Our goals and commitment to anti-racism center health equity, and partners eligible for this opportunity share these commitments.

Process

Grant Writing Stipend applications will be processed in the order they are received, and the application will remain open until December 31, 2024, or until funding is expended. If you have questions or would like to submit the request in a different language or format, email Ethan Senn: ethan.senn@betterhealthtogether.org.

 Application and approval steps:

  1. You complete the Grant Writing Stipend application (link below) with a specific funding opportunity and the name and contact information for your contracted grant writer. A PDF of the application is available at this link.

    • If you don’t know if you are eligible for the funding opportunity you have identified, you can request an eligibility coaching session with us by signing up using the form. We will send you a calendar invitation and Zoom
      link for the designated time.

  2. We review your request.

  3. We email you and the grant writer listed in your application to confirm approval for grant writing funding, collect more information, or deny funding if eligibility criteria are not met.

  4. You work directly with your grant writer to prepare and submit the grant proposal for this funding opportunity.

  5. You notify us when you submit the proposal and tell us the amount you requested.

  6. Your grant writer submits an invoice and their W9 to ethan.senn@betterhealthtogether.org. We pay your grant writer directly.

    • If this is for a 2024 grant project that is already complete or you would like the payment to be made directly to your organization, please send detailed invoicing from your grant writer showing the charges for their work on the approved funding opportunity.

  7. You let us know when you hear back about your application. We are tracking this information and are excited to know the results!

Frequently Asked Questions

Q: I don’t have a current grant opportunity in mind. Can I apply for these funds to use in the future?
A: No. Because of the way we are tracking the project, we need each Grant Writing Stipend to be matched with one funding opportunity. You must have an identified grant opportunity to receive the Grant Writing Stipend.

Q: After working with a grant writer on an application, we decided not to apply. Can the grant writer still invoice BHT for their time even if we don’t submit a completed proposal?
A: Yes. We understand plans change, and we want to make sure we are honoring the time of the grant writer involved. We will still pay for the hours your grant writer spent in exploring and/or preparing an application.

Q: My organization’s internal team has the ability to write this grant. Can we apply for funding to cover staff time?
A: No, we have set aside this funding for external technical assistance grant writers to increase resources going to CBOs.

 Q: I don’t have a grant writer. Will you help me connect with a grant writer?
A: We are not providing an approved list of grant writers; we encourage you to make direct connections and ask your community partners if they have recommendations.

Q: What does BHT expect after we hear back about our grant application?
A: As part of accepting the Grant Writing Stipend funds, you are agreeing to let us know the results of your application, whether or not you are selected as a funding recipient. We are tracking the overall dollars invested in community-based organizations through this initiative, and we will be totaling grant money received as a result.

Questions?

Contact Ethan Senn, ethan.senn@betterhealthtogether.org.

Helpful Terms

*Impacted communities: BHT uses the term impacted communities to refer broadly to all groups that have been impacted by systems of oppression, such as Black, Indigenous, People of Color, 2SLGBTQA+, persons with a disability, legal-system impacted, low-income, persons experiencing housing instability, undocumented community members, refugee/immigrant people, rural community members, and more groups that face inequity.

**Community-based workforce: We use the term “community-based workforce” to talk about our community workers, including doulas, peers, community health workers, and other community-serving individuals who aren’t employed by health care providers or insurance companies.  

Funding Opportunities: Rural School-Based Healthcare & Health-Related Social Needs of Students

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Updated July 2024: This opportunity is now closed. Announcement of awardees coming in Fall 2024.

Background

The Better Health Together (BHT) Board recently allocated $450,000 in regional Infrastructure dollars to support Rural School-Based Healthcare projects to increase access and provide rural students vital care. In January and February of 2024, BHT worked to gather feedback from rural schools and providers* to assess the needs and capacity within rural counties across eastern Washington. Based on that feedback, BHT is currently accepting proposals and expecting to fund between 6-10 projects, with a maximum of $75,000 per proposal.

In recognition of our Mission to radically improve the health of the region and our Vision of an integrated and anti-racist health system accountable for better health for ALL in eastern Washington, BHT is seeking proposals that demonstrate they will address socioeconomic, cultural, racial, geographic, and other health disparities experienced by students and their families in rural communities.

In addition, BHT has set aside $50,000 to meet the health-related needs** of students with ten (10) $5,000 mini-grants to schools.

Opportunities

School-Based Healthcare

BHT is seeking one- or two-year project proposals from healthcare providers and schools (grades preK-12) serving and based in Adams, Ferry, Lincoln, Pend Oreille, and Stevens Counties or serving and based in Kalispel Tribe of Indians, Spokane Tribe of Indians, and Colville Confederated Tribes sovereign lands.

Health-Related Social Needs of Students

In addition, BHT is offering a $5,000 supplement or, as a stand-alone, for the health-related needs** of students.

Please submit your proposals for one or both funding opportunities by May 15, 2024.  

Goals

Increase access to youth and families in rural settings to affordable, quality, and culturally relevant school-based health care in our rural counties. 

BHT will place priority on funding proposals that:

  • Include partnerships with local healthcare providers and schools.

  • Serving low-income and high-need students from impacted communities.***

  • Have a plan for sustainability once the funding has been expended.

  • Projects that demonstrate long-term strategies that address systemic inequities within rural communities.

What should proposals address?

This funding can be used to provide health-related services to students while they are in school. These programs or services could be telehealth/therapy, on-site and place-based, or mobile services.

In addition, BHT is offering a $5,000 supplement or, as a stand-alone, for the health-related needs** of students. This can include hygiene kits, weather-appropriate outerwear, safety and prevention equipment, and any other health-related need identified by the school administration.

The following criteria will be used to determine how funds are distributed:

  • Provider applicants must provide a letter of support and intent to partner from at least one school or School Board.

  • School District/Board applicants must provide a letter of support and intent to partner with a provider; partnerships with locally-based providers will be prioritized.

  • Proposals should include an expected budget and proposed sustainability plan once funds have been expended.

  • Proposals should include plans for outreach to those most impacted by healthcare access inequities and culturally competent care.

Funds cannot be used to pay Medicaid reimbursable expenses.

Timeline and Process

  • April – May 15 | Request for Proposals (RFP) Open

  • May 15 -30 | Review Committee Selects Awardees

  • June-August | Draft Statements of Work and Plans

  • September | Launch Projects

If you have any questions please contact Hannah Klaassen, Program Manager: hannah@betterhealthtogether.org.

Helpful Terms

*Providers: BHT uses the term healthcare providers, in this instance, to include but not be limited to primary care, dental, behavioral health, and specialty care providers.

**Health-Related Needs: BHT acknowledges there is more to health than primary care; it is also the access to social, physical, occupational, mental, and behavioral resources that make up the larger picture of what makes someone healthy. We recognize that all these areas are interconnected and determine a person’s overall health.  This can include hygiene kits, weather-appropriate outerwear, safety and prevention equipment, and any other health-related need identified by the school administration.

***Impacted Communities: BHT uses the term impacted communities to refer broadly to all groups that have been impacted by systems of oppression, such as Black, Indigenous, People of Color, 2SLGBTQA+, persons with a disability, legal-system impacted, low-income, persons experiencing housing instability, undocumented community members, refugee/immigrant people, rural community members, and more groups that face inequity.

BH Forum materials – April 2024

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Overview
In 2022, the Better Health Together Behavioral Health Forum allocated $1.2 million dollars of integrated managed care funds to initiatives that support the regional behavioral health workforce. Since that time, the Forum has been designing and launching these initiatives. Up-to-date information about active opportunities is located on this page, and this overview provides additional information about our behavioral health workforce investments!

April Meeting Information
April 3, 2024 from 10 to 11:30 am. Email Hannah@BetterHealthTogether.org for the Zoom link.

April Agenda

Helpful Information:

April Meeting Notes

April Meeting Slides

BHT Community Voices Council Slides

SFCC Integrated BH Student Council Thank You Letter

April Meeting Recording

Announcements

Have an announcement to add to this page? Email the information to Hannah: Hannah@BetterHealthTogether.org.

Guiding Principles document

Member Agreement

Previous meeting materials posted here

2024 Update: Behavioral Health Workforce Investments

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Better Health Together convenes a regional Behavioral Health Forum made up of organizations that provide behavioral health services and institutions that educate the behavioral health workforce. Using Integrated Managed Care dollars set aside by the BHT Board, this self-governing group designs and funds initiatives focused on the behavioral health workforce. This page highlights the way these dollars have supported the community-based workforce, clinicians, and behavioral health interns to strengthen behavioral health services in Eastern Washington.

This is a visualization of behavioral health workforce investments. Click this link for a PDF of the content.