Housing and Health Outcomes: Why Stable Housing Is a Health-Related Social Need

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Worldwide, 1.6-3 billion people have unsafe, inadequate, or unstable housing. While that seems like a difficult enough stat to solve on paper, this leads to many other problems. Homelessness has never been just a shelter issue; it has always been connected to health and wellness. Housing case managers have the difficult task of connecting homelessness to other related causes, finding a solution that meets them all.

In this article, we'll discuss how housing instability connects directly to health-related social needs, and how case management software can help service providers create big-picture plans that solve all of these problems.

How Does Housing Instability Relate to SDOH (Social Determinants of Health)?

Homelessness and housing instability is often directly related to health issues. Many people who experience homelessness also suffer from physical and mental health conditions. They're also more susceptible to infectious diseases, including Viral Hepatitis, Tuberculosis, HIV, and COVID-19.

Housing instability affects the following SDOH:

• Economic Stability: Homelessness makes it harder to keep a job and maintain income. Even then, low income and unemployment can lead to homelessness, with 35% of renters cost-burdened.
• Health Care Access and Quality: Since people experiencing homelessness often don't have health insurance or a primary care provider, they need to use emergency services, which increase cost of care.
• Environment: With unstable housing, people are exposed to unsafe conditions, extreme weather, poor sanitation, and inability to store important items like medication.
• Social Context: The stigma that comes with homelessness increases discrimination and can expose people to violence, damaging physical and mental health.
• Education Access: Frequent moves, instability, and survival needs can interrupt schooling, reduce graduation rates, and limit long-term employment opportunities.
• Transportation: People without stable housing and transportation struggle to get to appointments, pharmacies, shelters, benefits offices, or work.

Having a place to call home helps give security to individuals to ensure they can improve other areas of their life. But when it's unstable or uncertain, it makes it difficult to move forward.

A Closer Look: Health-Related Social Needs

While SDOH are a key indicator for housing, health-related social needs give key details to case managers about a client's specific need. Surveys showed that 68% of Americans have at least one unmet social need. These can be a trigger for homelessness, with even feelings of loneliness among adults leading to larger issues, including chronic conditions and a higher risk of mortality.

Other health-related social needs as defined by the CDC include:

• Receipt of food stamps in the past 12 months
• Food insecurity in the past 12 months
• Housing insecurity in the past 12 months
• Utility services threat in the past 12 months among adults
• Lack of reliable transportation in the past 12 months among adults
• Lack of social and emotional support among adults

Case managers need strong systems to track and understand health-related social needs at a client-specific level. Catching and caring for these early can help people remain housed.

A Step in the Right Direction: A Housing-First Approach and Other Methods

To combat housing instability, case managers and care coordinators implement tried and true approaches like Housing First, which has been shown to decrease homelessness by 88%.

When clients are housed quickly, there have been reported declines in substance abuse, people with mental health challenges are able to access care faster, and the homelessness-jail cycle can be broken.

Other effective methods to combat housing instability and stabilize SDOH include:

• Rapid-rehousing: Short-term rental assistance plus housing search help and case management can move people out of homelessness quickly and keep them housed while they regain stability.
• Permanent supportive housing: Long-term affordable housing paired with intensive services is effective for people with chronic homelessness, disabilities, or serious behavioral health needs.
• Critical time intervention: Targeted support provided during high-risk transitions, including discharge from hospitals, shelters, or other institutions.
• Flexible financial assistance: Security deposits, move-in funds, arrears support, utilities help, and shallow subsidies can remove immediate barriers that prevent someone from getting or keeping housing.
• Integrated care coordination: When housing, health, and behavioral health providers share information and coordinate follow-up, clients are less likely to fall through the cracks.

When case managers are able to work together to strategize the best solution in a shared hub, communication burdens are eased and progress can be measured effectively.

How Case Management Software Helps Care Coordinators Keep Clients Housed

While HUD requires the use of an HMIS system, the capabilities of each solution vary greatly. Case managers need a digital platform where they can create comprehensive care plans, track every client, and find the best housing solutions quickly based on the availability of different providers and services.

Here's how case management like PlanStreet helps care coordinators track SDOH and provide housing services quickly.

1. Assesses and Prioritizes Most Vulnerable Clients

Housing case managers need to understand a client's complete health history to give them the best solution. With case management software, they can see everything in the person's file in seconds, including:

• Housing history
• Eviction risk
• Income
• Credit issues
• Support needs
• Notes from other providers

Viewing these needs in a dashboard helps case managers see every need at a glance, allowing them to quickly prioritize care for the most vulnerable.

2. Creates Individualized Housing Plans

Care plans need to be a living document, ready to make changes at a moment's notice as the client's needs increase or decrease. Case management software creates a digital hub that's flexible to each client's needs. Case managers can add SMART goals, action steps, updates, deadlines, and more, each one tailored to a specific client with no template that's difficult to change.

3. Simplifies Referrals and Care Coordination

Up to 50% of SDOH referrals are left uncompleted. Referral tracking software allows case managers, healthcare providers, Medicaid partners, and other specialists to track the entire process, following up with either clients, referrers, or providers if needed to see what is stalling care.

4. Organizes Task Tracking for Critical Deadlines

Many housing voucher programs, housing assistance contracts, and other housing services require strict deadlines that clients must meet. Task tracking software helps case managers stay abreast of these deadlines and collect critical information from their clients, ensuring they are able to get the housing help they need.

Automated reminders can help case managers stay on top of:

• Application follow-up
• Document collection
• Inspections
• Recertifications
• Court or eviction-related deadlines

5. Streamlines Documentation for Always-Ready Compliance

Keeping methodical documentation is critical for client success and to remain compliant to grants and government requirements. Case management software creates a place to centralize case notes, forms, signatures, and service records. This reduces missed information between service providers, ensuring that everyone has the information they need to make the best care decision.

Additionally, it creates a hub for analytics to show proof of progress when applying for grants.

PlanStreet in Action: Bermuda Housing

Bermuda Housing Corporation manages public housing applications and supports residents with case management services. However, they did so across disconnected systems that required manual data entry with limited reporting, making compliance and performance tracking difficult.

They implemented PlanStreet to streamline housing intake and improve social case management. After doing so, they saw major improvements in:

• Operational efficiency
• Service delivery
• Reporting and compliance
• Applicant experience

Elevate Housing Outcomes With Help From PlanStreet

Stable housing is one of the most powerful factors in improving health outcomes, economic stability, and long-term wellbeing. When case managers have the tools to assess vulnerability, coordinate care, track SDOH referrals, and meet critical deadlines, clients are more likely to get housed and stay housed.

PlanStreet gives care coordinators a single platform to manage every part of that process, from intake and care planning to referral tracking and compliance documentation. Whether you are running a Housing First program, managing permanent supportive housing, or coordinating across multiple service providers, PlanStreet helps your team spend less time on administrative work and more time on what matters.

To learn more about how we can create a platform customized for your community health organization, housing provider, nonprofit, or agency, schedule a demo with us today.

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