Housing affects health outcomes

Homelessness worsens heath conditions, sometimes in surprising ways

By Markian Hawryluk / The Bulletin / @markianhawryluk

Bernie Crisman can’t remember how he came to be homeless or how long he had been living on the street before he was attacked last year. Four men threw a pillowcase over his head, assaulted the 56-year-old Bend man and stole his belongings.

Crisman, a U.S. Army veteran, ended up at the Veterans Administration hospital in Portland, where he underwent brain surgery to repair his head wounds and was treated for a hernia. He spent another six weeks at St. Charles Bend recovering from his injuries.

“They drilled a hole in my head the size of a dime,” he recalls. “I couldn’t think very good. I couldn’t talk. My equilibrium (was off).”

When the hospital discharged him, they dropped him off at the Bethlehem Inn, a homeless shelter in Bend. But Crisman soon found himself in another health crisis. Unwilling or unable to control his diabetes, his blood-sugar levels spiked, prompting shelter officials to send him back to the hospital. There, doctors discovered he hadn’t been taking his antibiotics either.

“Now his infection is serious,” said Donna Hines, a professional fiduciary, who holds the power of attorney for Crisman. “He got discharged. He didn’t have the means. He didn’t have a place to keep (his medication). He didn’t have the mental capacity to take the antibiotics, and now it became a serious problem.”

Crisman’s case follows a familiar script for homeless individuals in Central Oregon. Living on the streets, they develop acute health issues or chronic conditions that spiral out of control, avoiding any medical services until they can no longer hold out or are brought to the hospital by emergency personnel. They are treated but released back into the same conditions that exacerbated their health in the first place and wind up back in the hospital. With each trip through the revolving door of admission and discharge, these individuals churn up thousands of dollars in charity health care dollars without ever truly becoming well.

There is, however, a growing recognition among homeless advocates and health care officials that there is an inseverable link between housing and health, that individuals cannot remain healthy without a roof over their heads, and often risk staying housed without access to health services.

Moreover, analyses show the public funds spent providing health care and other community services to the homeless in this haphazard way far exceeds the money it would take to provide them housing in the first place.

Health care for the homeless

The 2014 point-in-time homeless count in Central Oregon identified 2,410 homeless people in Crook, Deschutes and Jefferson counties, up from 1,990 in the previous year. Advocates believe such counts reflect less than half of the true homeless population but are useful in recognizing trends.

For example, the number of chronic homeless — adults who have been homeless for more than 12 months or who had at least four episodes of homelessness in the past three years — increased from 256 in 2013 to 522 this year.

In November, the U.S. Department of Housing and Urban Development estimated there were about 610,000 homeless individuals nationwide, with more than 92,000 of those considered chronically homeless.

Studies have consistently shown that homeless individuals have high rates of illness, injury, death and being victims of crimes. Those, in turn, lead to higher rates of emergency room and inpatient hospital use.

A national study found that, on average, homeless individuals visit the ER five times a year, with an average cost per visit of $3,700. Moreover, 80 percent of those ER visits, the researchers found, were for exacerbations of conditions that could have been treated with preventive care.

Those numbers are the stark reality of trying to survive on the streets, exposed to the elements, with little access to healthy food or good hygiene.

“It exacerbates any pre-existing health issues and I think you can’t really talk about people living on the streets without mentioning the reality that large percentages are struggling with some form of addiction,” said Curt Floski, executive director of Shepherd’s House, a homeless shelter in Bend. “So you couple health issues with addiction issues, and you’ve got the making of a health crisis.”

Living in shelters or homeless camps in close quarters can expose the homeless to communicable disease. They have trouble controlling chronic conditions such as hypertension, high cholesterol or diabetes, with no place to store medications or syringes.

Eating what they can find or afford, they struggle to maintain a healthy diet. Soup kitchens and other charities primarily offer meals that are low in cost but high in salt, sugars and starch.

It’s a population with high rates of depression and mental disorders and significant substance abuse issues. Injuries do not heal properly because bathing or keeping bandages clean is not possible. Minor issues such as cuts or colds become infections or pneumonia, which become more difficult and more expensive to treat.

“What’s a simple leg wound or an abrasion or a blister goes untreated, gets infected — pretty soon they have cellulitis of the limb,” said Dr. Randall Jacobs, an internist with Bend Memorial Clinic, who provides care to the homeless through the Mosaic Medical mobile treatment van. “And then if they’re a smoker, if they’ve got hypertension or diabetes, they’ve got poor circulation.”

Jacobs had been treating one such homeless patient in the medical van. Over the course of 18 months, the man had one leg amputated, then the other. He was killed crossing a road in a wheelchair.

“We certainly see frostbite every winter. We see deaths from hypothermia,” Jacobs said.

The van saw another homeless man who incurred second-degree burns on his face and arms when his propane stove exploded.

John Morris, outreach coordinator for Central Oregon Veterans Outreach, routinely makes the rounds of the homeless camps, handing out food, clothing and other supplies. When harsh weather is on its way, he makes extra trips to urge the homeless to get into a shelter and out of the elements.

“Our goal at the start of the year is to make sure nobody dies throughout the year from the weather,” he said. “Our rule is nobody dies from the elements.”

During the last winter’s worst storm, one man didn’t heed the warning and lost his toes to severe frostbite.

“They’re suffering because of the way they live, so they’re obviously more prone to have to go the emergency room,” Morris said. “They don’t have primary care providers, most of them don’t have insurance, and they go in when its so bad they don’t have anything left to do.”

In the hospital, homeless patients cost on average $2,500 more per stay than patients with stable housing. According to the National Health Care for the Homeless Council, homeless individuals are three to four times more likely to die prematurely than others their age, with life expectancy as low as 41 years. No amount of health care, the group maintains on its website, can substitute for stable housing.

“No matter what you’re going to give them in terms of medical care,” Jerry Hollis, executive director of COVO, “you’re still going to push them back out into the environment.”

Discharged to the street

A 2010 tally found 184 emergency shelter beds in Central Oregon and another 185 transitional housing spots. But many of those have strict standards and long waiting lists, and, for the most part, aren’t set up to deal with persons dealing with significant health issues.

“It’s a tough spot for people,” Floski said, “There are just not any places they can go.”

Increasingly, hospitals are discharging patients from inpatient floors or the emergency room with the expectation that they will continue to recuperate under the watchful care of their family or loved ones.

“It’s fairly simple if you think in terms of ‘I’ve got a husband at home, I’ve got a wife at home, I’ve got children at home. These are people who can help me,’” said Chris Clouart, director of the Bethlehem Inn. “You can convalesce at home and it’s 10 feet to your kitchen, it’s six feet away to your bathroom. It’s all within distance for you.”

Residents at the shelter must be able to walk 50 yards across the parking lot for their meals. There isn’t sufficient staff to care for individuals with health care issues.

“We often get a lot of pressure from the hospital or the discharge nurse saying, ‘Well, why is it that you can’t take this person?’ I had one guy released to me two days after open-heart surgery,” Clouart said. “They often times don’t understand the circumstances we have.”

The shelter may take in individuals who simply cannot go back to the street if they can, for the most part, take care of themselves. On occasion, they’ve arranged for a home health nurse to come by and change dressings, but they’re limited in what sort of services can be provided there.

In one survey, published in the Journal of General Internal Medicine, 67 percent of homeless patients surveyed spent their first night after hospital discharge at a shelter, while 11 percent spent it on the streets.

According to the 2010 U.S. Department of Housing and Urban Development’s 2010 Annual Homeless Report, 7 percent of all homeless individuals and 13 percent of newly homeless individuals at shelters came directly from a hospital.

“We become the default solution in too many difficult circumstances,” Clouart said.

Hospitals can try to get public health plans, such as Medicare or Medicaid, to cover some time in a nursing home for such patients. Community health workers at the hospital often spend hours on the phone trying to find a place for a homeless patient. But if the hospital cannot find a place to send them or if the patients are unwilling, there is sometimes little choice other than to release them.

That, homeless advocates say, is a recipe for disaster.

“It’s not adequate to just discharge someone to the street, and say, ‘Listen, you need this dressing changed every day; you’re not supposed to walk more than this distance; you should be eating this kind of food; you need to take these medications; you need access to water,’” Clouart said. “It’s not adequate to discharge someone to a camp or to live on the street.”

Moreover, a discharge to the street or shelter, more often than not, means that patient will be back. A 2013 Yale University study that tracked 113 homeless patients treated in an urban hospital counted 266 admissions over a four-month period. Half of the patients were readmitted and 70 percent returned to the hospital, either as inpatient, emergency or observation patients, within 30 days. A discharge to the street or shelter versus other living situations, the researchers concluded, increased the risk for readmission.

“What happens to homeless patients after hospital discharge? Spoiler alert: They quickly end up back in the hospital,” the lead researcher, Dr. Kelly Doran, wrote in a letter to the health policy journal Health Affairs last year.

Hospitals are increasingly facing significant financial pressures to avoid readmissions. Medicare has stopped paying for readmission within 30 days of discharge, and in Central Oregon, St. Charles Health System receives a fixed payment for providing care to Oregon Health Plan (Oregon’s Medicaid) patients, so they could lose money if a patient is readmitted.

That makes finding a place to send homeless patients with lingering health issues even more important. In some case, it costs less for the hospital to pay for a nursing home stay itself than to risk the costs of a readmission.

“Just knowing that there is a such a high risk of them coming back in if we don’t do that, we’ll spend the money to place them,” said Alan Burke, manager of social work for the hospital system. “Patient self-determination still rules the day. If they’re a reasonably competent person, and they don’t want to take this medication, we can’t force it on them. We can’t put them in a situation they don’t want to be in. A bad decision doesn’t make them incompetent.”

Several years ago, the hospital set aside $16,000 to help homeless individuals with their medications.

“We’ve helped more than 100 homeless people in the last couple of years with their medications,” Burke said. “That’s gone a long ways to try to help stabilize them and keep them from coming back in.”

Those medications are distributed either to patients directly or to the shelters, which can make sure they’re being taken as prescribed. While the program fits in nicely with St. Charles’ charitable mission, there is a cost-saving component to it as well, further stretching the limited health care dollars available for charity care.

“The benefit clearly was to try to prevent rehospitalizations,” Burke said. “If they had to have an antibiotic and they took it, chances were much better that they wouldn’t come back in.”

One way or another, most of the costs of treating the homeless are passed on to the general public, either through tax dollars for public health programs or by raising costs to those with private insurance to cover the shortfall. But with the homeless relying almost completely on ER visits for their health care, it’s an extremely inefficient way to pay for it.

“It’s not just a hospital issue; it’s a community issue,” Burke said. “If you have homeless out there, that impacts the police services, same with the EMTs, there’s the Bethlehem Inns of the world — all those places get impacted. And if we’re doing free care, then we’re charging higher prices.”

Bridging the gap

Local providers have been trying to plug gaps in the safety net for the homeless as they can. Central Oregon Veterans Outreach for years has operated a mobile van that visits shelters and other locations where the homeless congregate providing free care.

“That kind of moves them into the system at Mosaic, and trying to triage their needs,” Floski said. “The goal of that is to try to provide wraparound services on the medical side with Mosaic and prevent that repetitious cycle of emergency-room visits.”

By improving their health, they hope to remove another obstacle to escaping homelessness.

That’s what happened with Jeff Holmes, a 60-year-old Bend man, treated in the van. Holmes had been a carpenter in Roseburg, but achy knees and a slowing housing market left him unemployed. He crossed the mountains to Bend but fared no better here. Last year, after five years of living on the street, his blood pressure was so high, the nurse in the mobile van thought the device for testing it was broken. Jacobs prescribed a generic blood-pressure medication, giving Holmes a gift card and a ride to Walmart to fill it immediately. When his blood pressure started creeping up again, Jacobs sent him to Mosaic Medical, a federally qualified health clinic that provides free or reduced-cost care to those with no insurance.

A subsequent blood test showed Holmes had a variant of high blood pressure that needed a specialized medication, and the staff helped him apply for a pharmaceutical-assistance program to get the drug for free. The clinic physician also prescribed a statin for his high cholesterol, and at the start of 2014 signed Holmes up for health insurance.

That allowed Holmes to see an orthopedic surgeon, who gave him a cortizone injection for his knees while he waits out the waiting period for a knee replacement.

“I’m pain-free for the first time in 10 years,” he said. “I couldn’t have taken an eight-hour job if it was offered to me. Now I can.”

Jeff Holmes works on preparing a batch of soup while cooking at the Family Kitchen last month. Until he had stable housing, his health conditions were hard to treat.

Ryan Brennecke / The Bulletin

Holmes had been working at the Family Kitchen, working his way up from dishwasher to cook. He works four-hour days, making 40 gallons of soup, grilling sandwiches and baking biscuits for the dozens of homeless who come there each day.

“People in our situation have a fear of even using the medical van because they’re afraid they’re going to get a bill. They don’t trust the system,” he said.

Instead they use the emergency room if they can’t hold out any longer.

“That’s the first place they turn because they know they’re not going to be turned away,” he said. “I know people here who use it on a regular basis. It’s a revolving door.”

Holmes was displaced from his camp by the Two Bulls Fire in June but was offered the use of an RV donated to COVO by a veteran’s family. The RV is parked on land owned by Christ Community Church, and Holmes also serves as the caretaker there. What started with a simple visit to the mobile health van now has Holmes on the path to being healthy and self-sufficient.

“Mosaic has put me back together healthwise, so I can go out and get a real job,” he said, “which a year ago would have been impossible.”

Holmes has also become an evangelist for Mosaic and Oregon’s health care expansion, and he demonstrated that last month in the soup kitchen.

“Does anybody here not have health insurance?” he bellowed across the room. A young man raised his hand.

“Would you like health insurance?” he asked. Indeed, the man would.

“You show up at Mosaic Medical on Monday morning; they’ll have it for you in two weeks,” he said. “See how easy that is?”

Jeff Holmes, who was once homeless, now cooks meals at the Family Kitchen in Bend for area homeless. He is an advocate for local homeless people to seek adequate health insurance and treatment.

Ryan Brennecke / The Bulletin

The Medicaid expansion under the Affordable Care Act has opened the door for many homeless individuals to get health insurance. Most didn’t qualify in the past because the program was largely reserved for mothers and children. That changed as of Jan. 1 with Obamacare but has exacerbated the discharge problem.

“We’ve had double the number of new patients that we thought we would. Over 2,000 of our uninsured patients now have OHP,” said Elaine Knobbs, Mosaic’s director of programs and development. “So now they have insurance, but they still don’t have housing.”

A national analysis found that three out of four chronically homeless individuals with incomes below the threshold for Medicaid expansion were not on Medicaid prior to the Affordable Care Act.

“We’re still early enough in this people having access to health insurance on a large scale, so that a lot of these things have not been resolved yet,” Clouart said. “We’re going to be dealing with folks who will have access to health insurance, but they don’t necessarily have access to stable housing.”

Now, homeless patients are more likely to seek care, be admitted to the hospital and have major procedures done. With no expansion in nursing home beds or transitional care, however, it has squeezed more homeless through the front door of the health care system without a clear exit strategy.

“We’ve never seen so many homeless people,” said Mary Meeko, executive director of the Pilot Butte Rehabilitation Center in Bend. “Because of Obamacare, the homeless people now have access to health care, so we’re seeing a greater number.”

This year, Pilot Butte has consistently seen two to three homeless individuals among its 30 to 35 residents.

But when homeless individuals no longer meet the medical criteria to stay there, the staff faces the same challenge that discharge planners at the hospital do.

“We start calling and asking,” Meeko said.

Even when individuals are placed in a nursing home after a hospital stay, they are often so concerned about their belongings in the camps or where they will go afterward, they don’t stay.

“They’ll give them up to two to three weeks (in a nursing home); after two days, guys get up and walk out the door,” said John Morris, outreach coordinator for COVO. “They’re worried about their stuff being stolen and they are not down with sitting.”

One of the vets Morris worked with was transferred to a nursing facility after a hip replacement.

“That guy left after a week,” he said. “They said, “Do not leave, do not leave,’ and he just waddled out. You’ll see him out there walking with a walker.”

Many of those individuals have gotten to the point in their lives where medical care simply isn’t a priority.

“To be honest, I don’t think they care,” Morris said. “They have nowhere to go. Their hope is pretty much gone. They’re trying to survive, trying to get rent for the day, trying to get food to eat — at the end of the day, medical issues just get in the way.”

Those medical issues then flare up, prompting someone to call 911 and then EMTs or the police bring them to the hospital. COVO sometimes gets the call when they are discharged but often has no good options for where to take them.

“We’re always willing to go pick somebody up; the problem is a lot of these guys are no longer welcome in the camps. They’re no longer welcome at the Bethlehem Inn. They’ve burned every bridge until there are no bridges left to be burned, and that’s when they end up underneath the bridge, literally.”

A housing solution

Most advocacy groups for the homeless as well as many health care providers now believe the solution may be to provide housing and support services. Known as the housing-first model or permanent supportive housing, the thought is that by placing homeless in housing and providing them with support services, they can break the expensive cycle of homelessness and its associated costs, and save money in the long run.

The model has been tested in many places around the U.S. and Canada and shown great success.

A Canadian study released in April, for example, split more than 2,000 homeless people between a housing-first program and traditional support services. It found that every dollar spent on housing and support netted more than twice that in savings in hospital, prison and shelter costs. The program spent $19,582 per person to provide housing and support services, but saved more than $42,000 on average. And 72 percent of those in the housing-first group had stable housing after two years, compared with 34 percent in the standard group.

Early this year, the Central Florida Commission on Homelessness released an analysis done by Creating Housing Solutions, which calculated that the region spends $31,000 a year per homeless person. In contrast, getting each homeless person a home and caseworker would cost about $10,000 per person.

The savings come not only from avoiding hospital and ER admissions, but cutting costs for EMT, police, jails and substance-abuse facilities. Many communities, however, have struggled finding the upfront money to invest in the approach. In some places, hospital systems have fronted the money expecting that they’ll reduce their charity care costs through the program.

But often, spending by one player in the community would results in savings for others, requiring a community-wide approach to the issue.

That’s where Oregon’s recent health reform effort could help. Under Gov. John Kitzhaber’s plan, money for Oregon Health Plan enrollees is given in a lump sum to coordinated care organizations, which can choose how to spend that money in their communities. The governor has frequently used the example of purchasing an air conditioner for an elderly patient to avoid an expensive hospitalization for problems stemming from the heat.

The housing-first model, it seems, could expand that approach from an air conditioner to an entire apartment.

The state provided CCOs with additional funds to help transform the health care system, and in Central Oregon, the CCO accepted proposals for how to spend its $1.6 million in transformation dollars.

One of the proposals was a housing-first pilot project, pitched by Housing Works of Redmond.

The Health thru Housing pilot sought $285,000 to provide rent assistance and case-management services for 20 to 25 homeless individuals who were pregnant or had chronic medical conditions.

Two-thirds of the funds would be used to pay rent and provide security deposits, while the remainder would be used for case management to help the homeless transition.

“We would basically take someone straight out of homelessness who has one of those conditions; we’d be putting them in housing, providing rental assistance, provide case-management services, and then document medical reimbursement costs on the program,” said Kenny LaPoint, Housing and Resident Services Director for Housing Works.

Homeless people with chronic conditions such as high blood pressure, high cholesterol or diabetes often end up in the emergency room because their conditions are not well controlled. Meanwhile, studies show women living on the street have a higher rate of pregnancy than those in stable housing. Some wind up on the street after becoming pregnant, but others become pregnant due to lack of contraceptive services, sexual assaults or survival sex while on the street.

Homeless women, however, rarely receive any prenatal care and have an extremely high rate of premature birth. Such high-risk pregnancies often result in longer hospital admissions for the mothers and expensive neonatal intensive care unit stays for their babies.

In Central Oregon, Grandma’s House provides shelter for pregnant teens but is limited to 20 women at any one time and doesn’t take adults.

“We firmly believe that if you get people in housing, you’re going to be able to limit these medical issues that folks are having,” LaPoint said. “Now they have a roof over their head, and they can think about their day-to-day maintenance of medical issues, finding employment, taking care of their family — all that stuff that you and I think about on a day-to-day basis, while homeless people are just trying to make it.”

Studies have shown the approach works even when individuals have alcohol-abuse issues, a strategy known as “wet housing.” A 2009 study in Seattle found average savings of $2,449 per person per month after accounting for the housing program costs.

Scarce homes

The Central Oregon Health Council, which oversees the local CCO, opted not to fund the Health thru Housing pilot, in part because of the difficulty in finding low-cost housing. The region’s fast growth and rising property values have made rental properties, particularly affordable rental properties, almost impossible to find.

“The housing crisis is pretty severe right now, so it’s scary for a lot of folks,” LaPoint said.

According to the Central Oregon Rental Owners Association, only 37 units out of 3,862 rental units in Central Oregon were available in May, a vacancy rate of less than 1 percent. Housing Works said only about 500 landlords currently accept rental subsidies.

That means even with assistance, individuals often can’t find a place to rent. Housing Works issued 60 housing vouchers at the end of last year, and another 200 this spring.

“In prior years, we had about a 70 percent success rate in people taking a voucher and using it,” LaPoint said. “Right now, we have a 25 percent success rate, and it’s because there’s nothing available.”

Part of the problem is that rents have quickly outpaced the fair-market rent rates set by the federal government and used to determine the size of the vouchers.

“The fair market rent has not been raised by the feds in Deschutes County for two years,” said Mary Marson, associate director of housing stabilization for NeighborImpact, a social-service nonprofit based in Redmond. “That’s when the recovery started to come in. So rents went up and, unfortunately, the fair-market rent didn’t recognize that.”

Currently the fair-market rent for a two-bedroom apartment is set at $678 in Crook County, $637 in Jefferson County and $803 in Deschutes County.

“You’ll be hard-pressed to find a two-bedroom in Deschutes County for $803,” Marson said.

And homeless individuals, with potential criminal records, eviction history, low credit scores and substance-abuse issues, must compete for those limited spots with employed candidates who have squeaky-clean records.

NeighborImpact has tried to address some of these barriers with its Ready-to-Rent certificate classes. Individuals are taught how to be good tenants and what their rights and responsibilities are, in hopes of making them more attractive renters despite their history.

“A lot of landlords are open to considering somebody who might otherwise have a not-so-good housing history. If they can show them this certificate,” Marson said.

Prevention

There’s also been a push locally to help individuals avoid homelessness in the first place by keeping them in their homes when health crises arise. NeighborImpact helped Patty Rutherford, 48, stay in her Redmond apartment when she needed a heart valve replacement last year.

Rutherford had spent time in jail for selling methamphetamine with her kids in the car. The conviction was a wake-up call, she said, and upon her release 14 years ago, she turned her life around. She worked for a long-term care facility before a new law barred the care home from employing individuals with criminal records. She then became a live-in caregiver, a job that required she be on-site 24 hours a day.

When her last client passed away, she needed a change and began working in a sandwich shop, until last year she was diagnosed with a heart valve issue. Unable to work or qualify for disability payments after her surgery, Rutherford was facing eviction.

NeighborImpact provided her with three months of rental subsidies to keep her in her apartment until she could return to work. When she was diagnosed with cervical cancer, they extended the assistance to a year.

“If it wasn’t for NeighborImpact, I would have been homeless with my sternum cracked open,” Rutherford said.

Now fully recovered, she has started her own housecleaning business. She must carefully monitor her intake of green vegetables to maintain the proper levels of blood thinner she takes because of the artificial heart valve, something she wouldn’t be able to do without access to a refrigerator and kitchen.

“Not everybody who is homeless in Central Oregon looks like the people you see standing on the corner,” she said. “There are good people with families, maybe like me, who have a troubled background but have cleaned up their life and done something with it. But then something happens where they’re right back at stage one again, right back at the beginning.”

Patty Rutherford plays with her grandkids, from left, Emma Schile, Tyler Schile, 5, and Chloe Tull, 4, in her Redmond apartment last month.

Ryan Brennecke / The Bulletin

Examples like Rutherford’s are helping housing and health groups as well as local governments begin to connect housing and health. Mosaic Medical will soon embed a nurse practitioner at Ariel Glen and Ariel South, the two biggest low-income housing complexes in Central Oregon, converting an old laundry room into an exam office. The clinic has taken over management of a school-based health clinic at Ensworth Elementary in Bend and will open a second school-based clinic at Bend High School in 2015.

Those could help increase access to health care for those who might be just a step away for homelessness.

“That’s where health is talking to housing,” Knobbs said of the Ariel plan. “But are we addressing homelessness? It’s a start.”

For many homeless, there are programs and resources that can be accessed if they want help. Hines, the fiduciary, is often called in when individuals can’t go back to the streets. She begins to search for money, for family, for resources to help place them in a stable situation. Often, individuals have access to funds they didn’t know about or didn’t know how to access. She can help with filling out the proper paperwork, getting them identification and screening potential destinations that best meet their needs.

“Sometimes it’s now knowing where to turn or what to do,” she said. “You’ve gotten yourself in a cycle for some time and you don’t know how to get out of it. Or you have resources, but you don’t know how to manage the funds that are coming in. They have to have ongoing help to not just get right back into that situation.”

With Crisman, she was able to place him at Pilot Butte Rehab for several weeks of antibiotic therapy and to get his blood sugar back under control. He made her promise him he would have a place to go after his discharge; otherwise, he would have left the rehab facility immediately.

“He doesn’t want to go back to the Bethlehem Inn and he doesn’t want to go back to the camps,” she said. “He’s very fearful.”

She found a place in an adult foster home, finding a caretaker whose son had diabetes and could help Crisman with his insulin and diet. “It has a TV, right?” Crisman asked her. That part was nonnegotiable.

“You know what? If it doesn’t, I’ll buy you a TV,” Hines told him.

The roof over his head and the television should keep Crisman off the streets and perhaps out of the emergency room for the time being. In his case, it’s easy to draw a straight line between an ability to manage his diabetes and a hospital readmission. For other homeless people, the connection between home and health might not be as clear.

“It’s penny-wise and pound-foolish,” Clouart said. “Often time when you prevent the disaster from happening, it means the disaster didn’t happen and people don’t pay attention. We’re more in the lines of if somebody has a wound, let’s put a Band-Aid on the wound until the wound heals. Nobody ever says, ‘What do you do about preventing the wound in the first place?’ And then you have to spend more money on the Band-Aid.” •