In 1991 the United Nations declared housing to be a fundamental human right, and the United States has worked to reduce overall homelessness by over 20 percent between 2005 and 2013.  However, homelessness continues to persist across the country, with the highest concentration in mid-to-large metropolitan areas and disproportionately impacts those living in poverty, people of color and immigrants. 

Those experiencing homelessness also have the highest rates of chronic mental, behavioral and physical disease have significant barriers to health care and affordable housing and a lower life expectancy.  Their use of emergency services for episodic care also leads to higher treatment costs.    

In this episode, I’m talking with Pete Toepfer, Executive Director of the Center for Housing and Health, a subsidiary of the AIDS Foundation of Chicago.  The Center’s mission is to honor every person’s right to a home and health care by bridging the housing and health care systems to improve the lives of Chicagoans experiencing homelessness.  The Center is also the lead agency for Better Health Through Housing collaborative; an alliance of 28 supportive housing agencies across Chicago and Cook County dedicated to collectively working with health care partners.  Most recently, through Pete Toepfer’s leadership, the Center has been selected as the administrator for the FHP. 


By the most recent report from the Chicago Coalition for the Homeless, in 2017, 86,324 Chicagoans were homeless. 

  • 81% of these homeless residents lived doubled-up in the homes of others 
  • 56% were African American 
  • 28% were Latinx 

Homelessness in Chicago also impacts the working poor, with: 

  • 21% of those experiencing homelessness over the age of 18 are employed 
  • Another 28% attended college or earned an associate’s or bachelor’s degree 

And many Chicago families with children and youth are also experiencing homelessness: 

  • A total of 34,870 families with children experienced homelessness 
  • 86% were doubled-up in the homes of others 
  • 24% were minor children experiencing homelessness 
  • CPS served 16, 451 homelessness students during the 2018-2019 academic year 

This year, the City of Chicago and its partners have collaborated to align funding towards a common goal through the Flexible Housing Program or FHP.  Through FHP, Cook County is able to rapidly house and provide supportive services to some of Chicago’s most vulnerable populations, including individuals experiencing homelessness who cycle through the criminal justice system and utilize hospital emergency rooms for care. 

FHP achieves this through pairing wraparound health and social services with a housing subsidy to support residents experiencing homelessness. The Program focuses on frequent-utilizers of crisis response systems such as hospital emergency rooms, police stations, paramedic calls, jails, and shelters. 


Let’s start with how the FHP is based on a best-practice housing model from Los Angeles.  In what ways did Chicago adapt this model to address our unique challenges in addressing homelessness? 


One of the really exciting things that we’ve done is that we’ve expanded the scope of who can participate in the flexible housing pool.  Los Angeles has an incredible and very committed effort on the part of County government.  We’ve gone beyond that to have an inter-governmental response, where we have the Cook County government, as well as the City of Chicago and the Chicago Housing Authority all working together from the public sector.  But we didn’t stop there.  We decided that we wanted to look across all the different stakeholders with an interest in ending homelessness and allow them an opportunity to participate. So with that, we brought hospitals, had conversations with managed care organizations, and we have philanthropy all at the table at the same time, working together towards the same end.  So we are making sure that everybody in this city has a home and decent health care. 


On top of that, we have what we call a Governing Board.  So the community and people who are interested in the flexible housing pool have a chance to help guide its direction.  Part of the Governing Board are people with lived experience of homelessness and soon to be people who might actually participate in the flexible housing pool.  They have the same power as any investor who is putting up a million dollars, because we know they are truly experts in what it means to be homeless, and can help us to craft the pool in a way that will be the most responsive and person-centered.   


The flexible housing pool also has an explicit racial/equity focus.  We use our data to look at different outcomes to make sure we are, in fact, aligned with serving the population that we’re trying to serve; and that’s in addition to making sure that people have real power at the Governing Board to make decisions about the pool itself.  Finally, we have a pretty unique tool for allowing people to participate.  We have an escrow account that holds all the money that investors put into the flexible housing pool.  Right now the City of Chicago is the holder of the escrow account and the Center [for Housing and Health] receives the funds directly from the escrow account as a way to bring the funds to one place.  That is the “pool” of the flexible housing pool.   


And lastly, we are doing amazing work with data.  So our partners at two different homeless management information database organizations; the Suburban Alliance to End Homelessness in Cook County, and All Chicago – along with our partners at Cook County Health have done a data match, where they are able to tell us who are the persistent users across these multiple systems.  Who is ending up in the emergency room or an in-patient in the hospital over multiple years.  Who’s touching the jail, cycling in and out, and who are staying in shelters or out in the streets for the longest periods of time. Those are the folks we’re trying to serve; those who have been failed by our system for too many years. 


Tell us more about the administrative role of the Center for the FHP. 


The flexible housing pool is really the latest chapter in the Center for Housing and Health and the AIDS Foundation of Chicago’s work to bring together the health care and housing worlds.  It started with a really important research study called the Chicago Housing for Health Partnership in the early 2000s, when we were really demonstrating the efficacy of the Housing First Model.  And that is still one of the most cited research studies around best practices Housing First and programs to end homelessness.  Also importantly, it showed significant reductions in utilization, in-patient hospitalization days, in emergency room visits and in-nursing home days.   


So that was in the early part of the story with our role, and the CHIP study was the genesis for the creation of the Center for Housing and Health as a distinct organization.  From there we began to work with our partners around other policy and research projects where we could see how people who were experiencing homelessness were interfacing with multiple different hospitals throughout the region.  How that homelessness is documented in electronic health records and who gets missed because if we’re not able to track who are experiencing homelessness, the chances that we’re going to be able to provide appropriate intervention to them decrease significantly.  And, at the same time, the Center [for Housing and Health] was helping to lead the Better Health Through Housing Collaborative, that you referenced earlier, that was a group of supportive housing providers who came together to say, with one voice, “Health care, we know you need us, but we also need you. How do we work together to make a true difference in our community?  And to show you we are going to be good partners, to build that trust, and to end homelessness for over 100 individuals over the last 4 years.  The Better Health Through Housing Collaborative was also able to reiterate what we knew from the CHIP study and from what we’ve seen from other national studies; that with high quality housing and great supportive services, that people do not use crisis services like emergency department or end up in-patient in the hospital at nearly the same rates.  And, importantly, if you’re making investments that there is a return.  There is cost avoidance and potential cost savings on the part of health care institutions; especially for those who are responsible for being payors.   


How does the FHP align with other housing and health initiatives of the Center? 

We recognize that if want to actually end homelessness, we need a bigger tent.  We’ve been biting around the edges and making, in my opinion, modest decreases in the number of people who are homeless in our city for a long time, and it’s not for lack of effort.  But it is for a lack of political power and political will.  As we continue to develop relationships with partners and for us, most importantly, in the health care sector, who have a tremendous impact on our city and the way that they can leverage their economic and political power to say “we understand that we have not just a stake in this, but a passion for it and a role to help end it”.  The Flexible Housing Pool offers that opportunity and also is a way for them to look at some of the folks that come to their institutions on a regular basis, who they don’t have a solution for; who just keep coming back and back and aren’t getting well because they don’t have the dignity of a home.  So the Flexible Housing Pool says “ok, we can help the patients that you have or the members that you have, and you can be part of ending homelessness for those individuals”.  Also, in thinking about this through a collective-impact model, where we’re not just stuck in our own lanes, but saying we all have a commitment to this.  We all want to be working together, and together we’re going to be able to end homelessness and be proud of the city where we don’t have our neighbors living in the streets. 


The FHP has already secured investments from non-traditional and cross-sector partners, including local hospital systems and foundations.  Who are these partners, what is the significance of their engagement with the FHP and how do they help to build sustainability? 


So the current investors in the pool are the City of Chicago, the Chicago Housing Authority, Cook County Health has made a commitment, the Blue Cross Blue Shield [of Illinois] foundation has made a commitment, Advocate Aurora Healthcare and UI Health have all made commitments to the Flexible Housing Pool to date.  And that’s in addition to a number of philanthropic partners who have helped to support the development and the facilitation of the pool.   


Sustainability is a huge question, because if we’re going to put someone in a permanent, supportive housing unit, where there’s a rent subsidy and strong supportive services that are what we like to call the “secret sauce” of the program, if that goes away after one budget cycle or one fiscal year ends, then we are doing a disservice to our community rather than making a true impact.  THe more investors we have at the table, the more stakeholders who are contributing to the flexible housing pool, the better chance that we will be able to stretch our dollars farther, have a multiplying effect with those funds and also have the funds to eventually begin to transition folks to other sources.  So that the Flexible Housing Pool serves as the payor of last resort, if you will, to transition folks to more traditional subsidy sources.  When we have more partners at the table, we have greater buy-in and the stakes become higher, so that any one investor has a little more pressure to stay involved and stay committed. 


Since the implementation of the program in March, how many residents have been housed? 


To date there are 40 people that have been housed, half of those are in their permanent, supportive housing units where they will likely reside for many years. The other have are in bridge units and have their own safe place to call home but is not the permanent destination. 


Help us understand Bridge Units. 

The idea behind bridge units is that we’re often working with folks that are living outdoors, in encampments, under bridges, on lower Wacker Drive.  We want to be able to meet someone, and talk about the Flexible Housing Pool, and then offer them a place to come inside that day.  We’re not quite there yet, to be able to do it exactly in the moment, but the bridge units are generally single room occupancy units where we have people move in for a short period of time so that they’re living in their own space and can conduct a proper housing search rather than coming from living under a bridge, then going to meet with a landlord, and putting in a housing application. 


Of those who are housed, do they represent the race, ethnicity, gender and age of those most impacted by homelessness in Chicago? 

That’s correct.  In fact, for folks who are the persistent [and]  frequent users that we’re looking at, there’s even a higher proportion of people of color. The Flexible Housing Pool is looking [to make sure] we’re serving them at multiple time points. So at the time of referral, does that align with the demographics?  And then, are people falling off in the process? Are they making it to housing in the first place so they’re staying housed?  So throughout those different time points, we are consistently serving the demographic that we’re intending.  


What, so far, have been the challenges to program implementation and housing placement? 

It is quite an effort,  but I also want to recognize that it is not one that we do alone.  We don’t do it alone because we have a large stakeholder group that has come to the table from the beginning to really vision this project, and that we talk to on a regular basis.  I mentioned the contributers, but I also think it’s important to recognize some of the other partners like the Chicago Department of Public Health, the Chicago Department of Family and Supportive Services, the Corporation for Supportive Housing.  They’re all key members of this group of leaders who are making sure the Flexible Housing Pool works as intended.   


And, yet still, we have these housing challenges, Kuliva!  Oh, and I didn’t mention the agencies that the Center for Housing and Health subcontracts with.  We consider them key partners, too.  Housing Forward, located in the suburbs.  Thresholds, Debra’s Place and Renaissance Social Service are part of the folks doing the direct work on the ground, so I’d be remiss if I didn’t acknowledge them, too. 


Thank you for acknowledging them! 

And so, what are we collectively still struggling with?  The first is, despite this amazing data match, we still have a hard time locating people.  So we’ve only located about half of all the people who are part of the initial cohort that we identified, and that’s in spite of many still returning to the hospital for care or at different health care sites operated by Cook County Health.  And, you might ask, well why is that?  If they keep coming back, why can’t you find them?  It’s not that we can’t find them, its that we can’t find them, and keep them, or find them again once they’ve been located.  And a big part of that is because folks often end up in the emergency department overnight, and to date we don’t have staff that can respond at 2am, and who can go to Stroger and engage folks.  We are talking about the solutions. We need to adapt to the realities of the lives of the people that we’re serving, so what do we do to stay true to that value of being patient or person-centered. 


This is a new program, and as any one who’s started a new program knows, there are hiccups in the way you designed the program, the way that you set up the process, the flow and the way it plays out on the ground.  We’ve experienced some of those growing pains in the first six months of operation, and the team has worked really hard to identify those challenges and then to implement solutions and to test those.  We also haven’t gotten people into houses as quickly as we’d like.  We talked a lot about housing as a human right, and making sure we can bring people to a safe space.  We still have room to grow in making sure we are able to get people into their homes as quickly as possible, and I will acknowledge that that’s a place that [Los Angeles] has a leg up on us to date, but we’re going to be there soon. 


What are the established measures of success for the FHP? 

THe first is around housing retention.  That people will stay in housing for at least 12 months from the time that we move them in.  That we can move people in quickly; as I’ve said, that’s an area that we’re still working on.  And that as we have these successful housing placements, and people stay in stable housing, we wrap the services around them, go to their homes to provide services, connect with care-coordinators, [and] that we’re seeing those reductions in crisis care at the hospitals, and that folks aren’t ending up in-patient or in nursing homes.  If we’re reducing the utilization of those services, we’d expect an accompanying decrease in costs. 


What can we expect in 2020? 

In 2020, I think first and foremost, you can expect to see every one of the initial referrals housed someplace safe. Whether its with the Flexible Housing Pool or another option they’ve identified.  The second is that we’ve planned to continue to expand, and that we’re not stopping here.  That we bring more health care partners to the table and potentially some other non-traditional partners to the table, so that we are making good on that commitment to looking beyond the traditional players and to engaging partners that maybe have been somewhat interested but not involved in the way that they could. 

Learn More about the Center for Housing and Health: 


Better Housing Through Health 

AIDS Foundation of Chicago 

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