I started my career at a state hospital but transitioned to a VA hospital in 2007. I had been a resident at the hospital and was familiar with the unit and population. The unit had 19 beds, and typically these were filled. Often, admissions were for crisis stabilization due to suicidal ideation, and recidivism was very high. Typically, an unmet need other than psychiatric care was being addressed in many of these admissions. Many of the highest-utilizing individuals were unhoused or marginally housed. In their lives, basic needs were not being met, and the hospital became a way to meet some of these needs. Admissions appeared to increase in times of extreme temperature or weather.
The impact of the lack of basic needs such as housing, food, clothing, support, and connection, though often discussed as being a paramount consideration in the utilization of care, can be difficult to show in practice. Maslow’s hierarchy of needs has often been referred to since it was posited by Maslow in 1943. Though we acknowledge the importance of these basic needs, the adaptation to practice is often more nuanced. The utilization of money and resources is cardinal to addressing these deficits in basic needs, and when lacking, often individuals utilize crisis services.
I have seen an eloquent translation of the delivery of housing and basic needs to decrease the need and utilization of crisis resources such as hospitalization. It happened gradually from the years beginning around 2010. The census on our unit fell, first with only a couple of beds being unoccupied, until around 2016 when our census was much closer to between 6 to 10. There is a natural ebb and flow ever-present in inpatient psychiatry, and there have always been attempts to explain these differences, including studying the effect of a full moon. Often, census fluctuations are unexplained, as it can be difficult to identify contributing variables. Though this anecdotal decrease in census initially appeared interesting, it still stood to be determined if this was a quirk or something different. After several years, I began thinking about the variables that may have impacted this shift.
In 2010, the Obama administration started monumental plans to reduce homelessness in veterans with the goal to end homelessness. The Department of Housing and Urban Development reported that between 2009 and 2015, homelessness in veterans was reduced by 50 percent. This mirrors the decrease in census on my unit by 50 percent or more. I became convinced that this legislation and the resources now available at my local VA to assist veterans in finding housing with a focus on sustainability and permanent solutions were the exact reasons for the decrease in the utilization of inpatient resources.
There had been an archaic belief that treatment should come before housing as the goal. This was based on public policy that had been standard practice for decades. As an example, treating substance use disorders prior to finding permanent housing was standard. This is contrary to our knowledge that basic needs are paramount to mental and emotional health and well-being. This radical shift in practice translated to housing an individual first and then providing supports to assist them with opportunities for employment, mental health treatment, and other resources available in the community and at the VA. At the VA, this meant giving veterans housing vouchers, case management, and a team tasked with engaging in this work at each VA. The approach addressed assisting homeless veterans and those at the highest risk of becoming homeless. Interim and immediate housing options were sought and utilized, at times partnering with local and state entities. All of this with a special concentration on families, realizing that housing families was integral to this mission.
Inpatient hospitalization is expensive, and often recidivism is quite high, with a high amount of dollars being spent on a small population of high utilizers. The cost of inpatient psychiatric care is around $800 to $1,000 a day. This would easily cover a month’s rent in the city where I practice. Often, once admitted, patients are hospitalized for several days. So, simply viewing this from the lens of the most financially sound decision, housing makes sense financially for hospital systems. From a humanistic approach, the expectation that individuals can pursue mental and physical wellness while not having stable housing is flawed and unreasonable.
This naturalistic example of public policy translating not only to cost savings in VA hospitals but also to a decrease in the utilization of high-cost resources and the improvement in the well-being, confidence, and safety of veterans who have benefited from this mission is a profound lesson. First, the need to continue to assess public policy and not continue archaic practices without evidence and also the continued practice of meeting basic human needs of populations before expecting psychiatric and emotional measures to improve. Many years post the initiation by the Obama administration aimed at the important mission to end homelessness in veterans, the landscape at local VAs looks different to me and more hopeful. Other hospital systems and policymakers should examine this example of observational data showing, in a longitudinal manner, the impact of these measures. I hope there will be research and a wider examination, although my observation is anecdotal; it is an example of what we posit to be true potentially translating into improved outcomes in a population.
Courtney Markham-Abedi is a psychiatrist.