Housing provides much more than a roof over our heads – it serves as the foundation for our overall health and well-being. Today, as the coronavirus pandemic continues to sweep through our nation, where we live now matters more than ever before. But long before the COVID-19 crisis hit, millions of people with low incomes and people of color around the country faced a constant struggle to find a safe, affordable place to call home.

In Atlanta, Georgia, the city’s historical and current housing policies and practices have resulted in significant health disparities amongst residents in Black and Brown communities.

For example, according to data from the Georgia Department of Public Health in July 2020, Black people in Fulton and DeKalb counties are five times more likely to have asthma than whites. And maternal mortality among Black women in Fulton County is 94 per 100,000 births, far exceeding even the national rate among Black women of 42.8 per 100,000.

“Housing is the first social determinant of health,” said Kathryn Lawler, executive director of the Atlanta Regional Collaborative for Health Improvement. “It impacts every other part of your life.”

But it takes much more than health care to improve health outcomes. Tackling complex issues like housing and structural inequities requires aligning resources and expertise from multiple sectors and a making a multi-year commitment to create change.

Since 2011, the Atlanta Regional Collaborative for Health Improvement (ARCHI) has worked with more than 100 organizations aligned around a shared commitment to addressing systemic challenges and improving health in the metro Atlanta area.

“At the center of that commitment is a social determinants of health framework. Certainly, we have excellent clinical care in our community, so we want to help address all of the other factors that have been holding people back,” Lawler said.

As part of its Advancing Health Equity through Housing initiative, The Kresge Foundation awarded ARCHI funding in 2019 to develop a plan to reduce health inequities in the Atlanta region by addressing substandard housing conditions, housing access and affordability.

Working together with partners like Grady Memorial Health System, St. Joseph’s/Mercy Care Health System, Hope Atlanta, United Way of Greater Atlanta, Kaiser Permanente, and the Fulton and DeKalb County Boards of Health, ARCHI took a two-pronged approach to centering housing to achieve health equity in the metro region: integrating health and housing services to address the unmet social needs of area patients and driving health care investment to increase the supply of affordable housing.

Integrating Housing Support to Achieve Health Outcomes

If a person is worried about being evicted, following nutritional guidelines to manage diabetes may not be a top priority.

This is just one example that shows that if someone is not living in safe housing that is stable, it’s really hard for them to work on any of the other things that affect their health, Lawler said.

To help solve this challenge, ARCHI worked with its partners to design Community Resource Hub pilot projects at Grady Health System, a large safety net hospital, and Mercy Care Health System, a local network of Federally Qualified Health Centers, that launched in January 2020.

“At these hubs, we work with individuals with chronic disease like diabetes and hypertension and help address their unmet social needs, of which housing is a dominant need, and then monitor how that improves their health,” Lawler explained.

Here’s how it works: community health workers assess patients’ needs and help set goals that are meaningful to them. Then the community health worker identifies partners in the network who can help meet those needs. Through a coordinated series of warm hand-offs, case conferences and multi-agency problem solving, patients’ needs are not only met, but they no longer have the burden of navigating a complex system of housing, food, transportation, workforce and benefits counseling providers.

“It’s very person centered,” Lawler said. “Giving someone a fact sheet on how to get their diabetes under control isn’t enough. You’ve got to align it with something that’s meaningful to that person, like ‘you’re not happy because you can’t walk your grandchildren in the stroller, because you don’t feel good enough.’”

As an accountability partner, the community health worker helps the patient get the necessary services, while guiding and encouraging the adoption of lifestyle and behavior changes that have been difficult in the past.

And early results show that it does work, Lawler said. Even when COVID dramatically altered clinical operations, the organizational relationships that had already been built meant that project staff were able to adapt and offer telephone and virtual visits with patients.

Another said that “Prior to working with [the ARC counselor], my exercise is only walking from home to the grocery store. But now I go 2 miles beyond the grocery store and turn back. She let me know that exercise helps with diabetes.”

Though in-person visits are slowly ramping back up, telephone counseling has been so successful that they plan to continue this service, Lawler said.

Increasing Affordable Housing Supply

But there’s larger systemic issues at play, Lawler noted, so she said that they knew that the second prong of the approach had to look at the overall housing system and housing supply.

“The second prong was really trying to think about changing the game. Coordination doesn’t create new housing, and you can’t coordinate somebody into a unit that doesn’t exist,” Lawler said.

So after a year of studying how health systems around the country have invested money in affordable housing, six health system and insurance company CEOs made a public commitment in December 2019 to develop a shared investment strategy to support affordable housing production in 2020.

For the first three months of the year, work progressed as planned. Then COVID came. But because of the contacts, relationships and trust that had been built over the page year, the group was able to pivot and focus on meeting the immediate housing needs of COVID-positive patients who were homeless.

Working closely with Partners for HOME, the health systems were able to rapidly identify homeless people who came to their hospitals testing positive with the coronavirus, transfer them to a quarantine facility and provide additional medical support to ensure their recovery.

Even though the timeline has slowed, and the health systems are in a very different financial place than they were a year ago, all systems remain committed to the development of a joint investment in affordable housing, Lawler said.

The good part is they’ve stayed at the table. They’re still meeting. They’re still working on what that strategy would be.

“While the COVID-19 pandemic has changed how we achieve these goals, the work has continued and the relationships between health and housing providers are even stronger than we had hoped,” Lawler said.

“So while we’re not doing the spreadsheets and thinking about the investment pools like we thought we would be by this time in 2020, I think we’ve proven that the shared knowledge and understanding led to rapid action, which has dramatically improved the health and housing coordination needed during the pandemic,” she added.

As the situation evolves, the tasks may change, but the values stay the same. ARCHI will continue to convene partners and facilitate the rapid, real-time learning that has been a hallmark of this work.

“We’re learning through real, operational, day-to-day effort that bringing health and housing together to achieve equity is a lot easier said than done. Silos are a real thing. But what we have also learned is that we have to hold the space for people to braid together urgent work and systems change, and not to see those as a binary choice,” Lawler said.

“But we can point to local projects that are braiding those two things together and say, this is how it was operationalized, this is how it can be scaled, and this is how we can deliver that today.”