Newsroom | Community Health

Jodie Jepson (middle) and ABQ StreetConnect Navigator Jennifer Regan speak with a housing-insecure individual in Albuquerque, New Mexico. 

Helping Housing-Insecure Members Find Stability

Melinda Hutton struggled to find stable housing for years before landing on her feet.

In 2019, she moved out of her father’s house in rural New Mexico and into an Albuquerque nursing home. Financial trouble quickly shut down the facility, forcing her into a new nursing home nearby.

Then in 2020 the pandemic hit, and Hutton spent nearly seven months confined to her room due to chronic obstructive pulmonary disease and other medical conditions while elderly residents passed away around her.

She soon found herself undergoing treatment for kidney failure in a local Albuquerque emergency department. After a seven month stay, discharge orders left her with nowhere to go. Hutton, a Centennial Medicaid member through Health Care Service Corporation’s (HCSC) New Mexico health plan, was referred to a program called ABQ StreetConnect, for temporary housing.

“I’ve been living in nursing homes for 12 years, so I didn’t have any rental history,” Hutton says. “I would have been dead on the street, but they got me into a motel. I call them my guardian angels.”

HCSC care coordinators work with ABQ StreetConnect, operated by the nonprofit Heading Home, to secure emergency and long-term housing for chronically homeless and housing-insecure individuals. The program targets high-need, high-cost utilizers of emergency services, many of whom also struggle with severe mental health and substance use problems.

The program aims to help participants with housing and social health needs so they can focus on their health goals and utilize preventive, rather than emergency, health care services, says ABQ StreetConnect Executive Director, Jodie Jepson.

“If no one is going to find support for these individuals, then we are just leaving unhoused people with complex needs out there to die,” says Jepson, who founded the program in 2017. “That's not acceptable in our community.”

Street medicine

In 2020, HCSC’s New Mexico health plan began working with Heading Home because its navigators were running into members on Albuquerque streets.

ABQ StreetConnect’s eight navigators comb neighborhoods on foot to identify and connect with unsheltered individuals. Navigators also work with local hospitals to meet patients leaving health care facilities and safely transport them to clinics or doctor’s appointments. Local hospitals can refer patients to the program and help coordinate health screenings and other medical services on city streets, a tactic known as street medicine.

A key part of the program is collaborating with the Albuquerque Police Department, Albuquerque Family and Community Services and other groups to perform data-driven outreach. Once enrolled, navigators then work to establish long-term relationships with individuals and connect them to income and family support services, behavioral health care and other resources.

“When members are on the street, they’re caught in the same crisis over and over,” says Mackejo Heard, director of clinical operations support at HCSC. “This program (ABQ StreetConnect) is about being there and not giving up on them. That’s where Heading Home’s philosophy matches our own.”

ABQ StreetConnect has enrolled 237 unique participants since it was founded in 2017, and New Mexico health plan members can at times account for up to 70 of the program’s participants, Jepson says. So far during 2022-23, the program served 70 members and permanently housed 56% of those individuals.

Twice a month, HCSC care coordinators and clinicians meet with ABQ StreetConnect staff to discuss those enrolled in the program and locate members without an address on file who may be homeless. Participants may need care coordination, referrals, prescriptions or simply peer support, Jepson says.

Their efforts are paying off. New Mexico health plan members participating in ABQ StreetConnect between January 2021 and June 2023 had a 55% drop in emergency department visits across several Albuquerque-area hospitals. During that same period, behavioral health admissions dropped from 46 admissions to 17, and behavioral health readmissions declined 71% from 17 to five.

These shifts, in part, led to a 43% or nearly $700,000 decline in medical costs from 2022-23.

“This has been an amazing opportunity to start caring for people medically without going to the hospital,” Jepson says. “We're seeing decreases in ED visits and increase in outpatient care, and that's what we want over time.”

In September, HCSC’s New Mexico health plan and ABQ StreetConnect launched a pilot targeting 10 medically complex members in Bernalillo County who are chronically homeless and high utilizers of hospital and emergency care. It’s the first arrangement in New Mexico to have a managed care organization pay for housing, social support services and primary care.

The pilot has one navigator dedicated solely to New Mexico health plan members and includes comprehensive care management, care coordination, prevention and health promotion, and medical and non-medical transportation, among other services.

Short-term emergency housing

HCSC’s work with Heading Home also extends to short-term respite housing for men who are medically vulnerable or chronically homeless and discharging from an emergency room, hospital or rehabilitation and other inpatient care settings.

One bed at the Albuquerque Opportunity Center (AOC) shelter is reserved for New Mexico health plan members. Care coordinators typically receive referrals from local hospitals and screen patients to ensure they qualify and agree to be part of the program.

Once accepted, participants receive 24-hour care for up to 30 days and case management to assist with income, disability or other needs on their path toward recovery. The AOC campus includes medical exam rooms, a library, computer lab and other resources.

“Many of the clients we serve get turned away everywhere they go or receive empty promises — we don't want to be more of that,” says Jesse Hugg, executive director of AOC. “Many of these guys are just in a tough situation. This gives them their dignity and respect back. It builds them up as people.”

The respite housing program has helped members get back on their feet while leading to more cost-effective care.

In 2021, the program housed seven health plan members, leading to a nearly $90,000 decrease in medical costs six months after their respite stay, compared with the six months before enrollment.

Moving forward

For three months, Hutton lived in her motel room while her navigator visited up to twice a week, dropping off prescription medications, driving her to doctor’s appointments and helping secure permanent housing.

Then on Hutton’s birthday this past February, ABQ StreetConnect secured her an apartment in Albuquerque through HCSC’s Value Added Service housing program. She now proudly pays her own rent and says her medical conditions and mental health have both improved.

She is saving money to move into a house in Santa Fe and return to work, and she continues to appreciate the ongoing relationship with the program. “They have been an absolute blessing to me and a lot of other people in this building.”

Health Care Service Corporation, a Mutual Legal Reserve Company.