Dr. Bechara Choucair, chief community health officer for Kaiser Permanente, speaks to an audience July 17 in Berrien Springs, Mich., as part of Community Grand Rounds: Healing the Trauma of Racism.
Kaiser Permanente and Community Partners Move Homeless into Housing and Work to Keep Apartments Affordable 

By TED HARTZELL                                                                                                                                                                                                  CGR Communications

BERRIEN SPRINGS, Mich. – Who were these people living on the streets? That’s what the huge health system and insurer Kaiser Permanente wanted to know.

To get a more intimate feel for the homeless people 50 years old and older with at least one chronic medical condition in its headquarters city of Oakland, Calif., Kaiser partnered with community-based organizations that have staffs culturally sensitized to communicating with homeless individuals. They met homeless people in shelters, on the streets and in tent cities. They got to know those 50 and over, all 515.

Even by name.

This intimate knowledge was evidently a key emotional catalyst for organizers who led a successful effort to move a great many of these individuals into permanent housing this year.


Beyond Hospitals’ Walls

Dr. Bechara Choucair, who oversees Kaiser’s community health efforts in cities totaling 68 million people where the health system’s facilities are located, primarily in the western U.S., told this story July 17 at the Howard Performing Arts Center on the Andrews University campus. Using data and personal stories with emotional power, he emphasized the supreme importance of the overall health and well-being of any community for the benefit of every individual’s health.

“As an organization we truly believe what we do within the four walls of our hospitals and medical office buildings impacts probably 10 to 20 percent of the health of our members,” said Dr. Choucair, who is Kaiser’s chief community health officer. “What truly impacts the health and well-being of our members is what happens in the communities where they live and play and learn and work.”

“What truly impacts the health and well-being of our members is what happens in the communities where they live and play and learn and work.” – Dr. Choucair

His presentation was the first in the 2019-2020 season of Community Grand Rounds: Healing the Trauma of Racism. CGR, a collaboration of the Todman Family Foundation and Spectrum Health Lakeland, is in its second year.  This project seeks to bring Berrien County residents the latest information from experts on the health damage caused by chronic, systemic racism. Ultimately CGR plans to work with residents toward solutions, particularly for the Benton Harbor area, where predominantly black residents suffer earlier deaths and more chronic illnesses than people in most of the rest of the county. (For more information on “Health Inequities in Berrien County, Michigan” see info graphic.)


‘Social’ Return on Investment

Dr. Choucair did not specifically address racism. But his recommendations fit in with CGR’s emphasis on community health. Kaiser Permanente—the full, formal name is Kaiser Foundation Health Plan Inc. and Hospitals—is one of the country’s leading integrated health systems, meaning the non-profit system is both a health care provider and insurer. It has 12.4 million members, and he pointed out that his system has a built-in financial incentive to have members as healthy as possible and thus minimize insurance costs. A healthy return on investment is always a motivator.

But throughout his talk, he said the “social return” on investment outweighs the financial return. He talked about how Kaiser seeks the right partners to make its communities healthier in a great variety of ways. He addressed four main areas: housing, schools, economic opportunity including jobs, and environmental stewardship. (See accompanying story, “Schools, Businesses, the Environment” for a look at the latter three areas.)

Dr. Choucair spent more time and emphasis on the role of housing in health, saying the nation is in “a housing crisis” caused, in part, by flat median household incomes for renters from 2001-2017, while rents (including utilities) increased nearly 11 percent. As a result, some people have been forced to live in substandard housing with unhealthy conditions such as lead paint and mold, causing problems including poisoning, asthma and unintentional injuries. The annual toll to the U.S., in dollar terms, is an estimated $309 billion.


The Housing & Health Equation

Housing and health are “so interconnected,” Dr. Choucair said. Eighty-nine percent of Americans say safe, stable housing is very or extremely important to overall health. Homeless people’s lifespans are on average 27 years shorter than those of people in stable housing, and the homeless are at greater risk for communicable diseases and some chronic illnesses. Homelessness is increasing in most of the communities served by Kaiser Permanente. In 2018 alone, 918 people died on the streets of Los Angeles, he said.

The health system is working with partners for housing at the local, state and national levels. “We have to be serious about leveraging a huge tool in our toolbox that has a humongous impact, and that’s policy,” he said.

At the local level, he said the health system is using nine “evidence-based, bipartisan policies that any city could really roll up their sleeves and make happen.” One policy is inclusionary zoning. It is a method a local government can use to require or encourage developers to set aside a certain percentage of housing units in new or rehabilitated projects for low- and moderate-income residents.

At the state level, Kaiser has identified certain strategies and policies. Last year in California it advocated for more funding for housing for veterans and people with mental illnesses.

At the national level, the health system is part of a coalition of 24 bipartisan mayors and companies’ CEOs from cities it serves. Dr. Choucair said the coalition believes the federal government has a role in furthering housing policies.


Partners for Housing

The health system wondered how it could improve the supply of affordable housing, either by preserving existing housing or expanding the supply. Because Kaiser doesn’t have housing experts, Dr. Choucair said it partnered with experts from community development financial institutions, or CDFIs.

Using money it otherwise would have invested in the stock market, the health system is dedicating up to $200 million through the CDFIs to help preserve and expand affordable housing. The money supports loans in all the health system’s communities. It also supports an effort to identify buildings that are at risk of losing their affordability for renters. The health system works with not-for-profit community developers to get equity in those buildings, with the goal of preserving affordability for many years.

Through the equity fund, the health system recently bought a building in East Oakland, Calif., that was about to become unaffordable. Dr. Choucair said the very first person staff talked with in that building was a woman who is a Kaiser member with multiple medical problems and who takes many medications. “She said if her rent had gone up by 100 dollars—100 dollars” he said a second time—she would have been out on the street.

As with other community efforts, he said this is an instance of the health system reaping some financial returns on its investments, but far greater “social returns” in uplifting the community.

“She said if her rent had gone up by 100 dollars—100 dollars” he said a second time—she would have been out on the street.


A Turning Point: Judy’s Story

Dr. Choucair is a Lebanese-born man in his mid-40s who grew up amid his native country’s civil war. In the U.S., among other roles, he has worked as a family physician at a program for homeless people in Rockford, Ill., and as head of the Chicago Department of Public Health.

An audience member asked him if there was a pivotal event, a piece of research or something else that led him to enter the field of community health.

He said there were many such moments, but the most important concerned Judy, a patient of his in her mid-30s in the Rockford homeless program. He described Judy as a “fantastic person” who was always smiling. But she had bipolar disorder and struggled with substance abuse. At night she slept in parks or shelters. Once Judy told Dr. Choucair, “Stop talking to me about all these medications.” Instead, she said she was worried about where she would sleep at night during the coming winter. She feared she would end up dying in a park.

“So we knew, every time that I would see Judy, that would be in the back of my mind,” he said. “And you can imagine the day I heard that somebody was found dead due to hypothermia in the park, and it ended up being Judy.  I felt like I failed her. I felt like our systems had failed her, our policies had failed her, and I figured that I should be able to do better for her, for her memory and for the Judys of the world.”

“And you can imagine the day I heard that somebody was found dead due to hypothermia in the park, and it ended up being Judy.  I felt like I failed her. I felt like our systems had failed her, our policies had failed her, and I figured that I should be able to do better for her, for her memory and for the Judys of the world.” – Dr. Choucair


Fighting for Other ‘Judys’

Dr. Choucair got an important opportunity to help some of the Judys of the world this year in Kaiser Permanente’s effort mentioned above to find permanent housing for many of Oakland’s 515 homeless people 50 years old and older, each of whom had at least one chronic medical condition.

He acknowledged that for most of its 12.4 million members the “data-driven organization” can readily summon up data to help devise medical interventions. “In a heartbeat I can tell you exactly who are the members who don’t have their blood pressure well controlled. Or who are the people who need to be on ACE inhibitors (drugs to lower blood pressure), but they’re not taking ACE inhibitors. But in the social services space, we have a way to go when it comes to using data.”

That was why the health system turned to people trained to deal with homeless individuals.

And now “we know them by name. We know their faces. We know their stories. We know where they are” and the medical condition of each.

Armed with this information, “we challenged ourselves and our community partners and we said, ‘What would it take to get every one of those 515 people off the streets into housing?’” Dr. Choucair recounted.

Critics were plentiful. They told Kaiser to “fail fast” and get on to other things, because housing the homeless wouldn’t work. But he said the effort that began in February 2019 had by June 1 found stable housing with long-term leases for 317 homeless people. “And when you see them in stable housing, it changes the conversation completely.”


No Googling Around Needed

On another beyond-the-hospital-walls concern, he described a dilemma for doctors.

If a physician suspects a patient is suffering from lack of something as vital as good housing or enough food, it can be a predicament to ask questions of the patient. After all, a physician is not a social service agency. And what if the doctor really is not prepared to make a referral to an agency?  As a result, the physician might not ask at all, even though Dr. Choucair said a Kaiser poll found that 97 percent of respondents want medical providers to ask about social needs during care visits.

He said the health system is working to solve the “don’t-ask” dilemma in all its 39 service areas by linking its doctors, nurses and social workers seamlessly to a network of social service providers through a dual interface with its electronic health records system. Those electronic records will have information about each insured members’ physical, mental and social health.

“Now, when our doctors, our nurses, our social workers are asking those questions, they know exactly who to refer to, and they can do it right from their electronic health records system. It’s not log in, log out, log in to the Internet, do a Google search, find a phone number and give the phone number to the person,” he said.

The health system also plans to make this system available to members for self-referral. Dr. Choucair said some people might be uncomfortable or even feel ashamed about coming to doctors and nurses and talking about something like food insecurity. But from the privacy of their homes they can go on a Kaiser app and find and connect with resources.