Only 20% of U.S. nonprofit hospitals invested in housing as part of the federal community benefit mandate

A nationwide assessment of how nonprofit hospitals are addressing housing-related needs in their communities appears in the latest issue of Medical Care.

"Approximately 60% of hospitals in the United States are 501(c)(3) nonprofit organizations and are legally required to address substantial health needs in their communities as a condition for tax exemption," explain Berkeley Franz, Ph.D., Associate Professor of Community-based Health at Ohio University in Athens, Ohio, and colleagues. Housing-related factors are a well-documented social determinant of health, found in multiple studies to affect individual health conditions such as hypertension and chronic disease, child development disorders, and mental health disorders.

The Patient Protection and Affordable Care Act introduced additional requirements: Nonprofit hospitals must complete a triennial community health needs assessment and corresponding implementation strategy. Dr. Franz's group, which included 7 medical students, analyzed a national dataset of those records, randomly sampling 20% of all nonspecialized nonprofit community hospitals within each state.

The researchers found that of 433 hospitals studied, 346 (80%) did not mention their community's housing needs within their implementation strategy. Of the other 87 hospitals, 29 (7%) documented only one strategy they are using to address housing needs.

Multiple strategies are being used to address housing insecurity

The hospitals that mentioned housing needs in their implementation strategies collectively listed 302 strategies for addressing housing insecurity. The most common was collaboration with community and hospital-based partners to increase access to affordable housing initiatives, housing assistance, and employment for low-income residents, mentioned in 103 strategies (34%).

These strategies "may allow hospitals to work with the community organizations that have prior expertise and funding in housing, providing hospitals with a foundation upon which to build their own programs," the researchers note.

The second most common strategy (21%) was to provide financial assistance for temporary and transitional housing. Directly asking patients about their housing status and other social determinants of health was one of the least common approaches (9%), even though it is perhaps one of the most actionable.

Characteristics of nonprofit hospitals that address housing-related needs

In general, hospitals that addressed housing in their implementation strategies were:

• Larger
• Urban
• Academic medical centers
• In communities with high income inequality
• More likely to be serving populations where severe housing needs are common (more than one person per room; monthly housing costs exceed 50% of income; lack of a sink, stove, or refrigerator; or lack of hot and cold water, a toilet, or a bathtub/shower)

The latter finding suggests that "at least for housing, hospitals are making charitable investments in ways that are in alignment with local needs," Dr. Franz and her co-authors say. They speculate that larger hospitals and major teaching hospitals are better positioned to obtain funding or federal grants than smaller hospitals with fewer resources for research and outreach.

"Understanding the way hospitals currently address housing insecurity is an important step toward developing effective interventions," the authors point out. "Future work should focus on supporting cross-sector partnerships and the integration of social determinants of health into hospitals' community health programming."