This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

Myrna*, a double amputee, lives on the streets in Grand Rapids’ Heartside district. Every morning, she is roused from the doorway where she sleeps and elicits help to get back up into her wheelchair. As a woman experiencing homelessness, Myrna lives an unsheltered, uncomfortable, and unsafe life – and her medical fragility puts her at even higher risk of harm and poor health.

With funding from the Michigan Health Endowment Fund, the Michigan Department of Health and Human Services (MDHHS) is developing a new system to identify unhoused Michiganders like Myrna, who live with chronic illness or disability, and help them find homes as quickly as possible. MDHHS will create a standardized, statewide indicator to track not only an individual's homelessness risk but also their medical fragility. 

"When somebody is experiencing homelessness, they're obviously in a state of crisis," says Lynn Hendges, MDHHS' manager of housing and homeless services. "Right now, the way that information is gathered, particularly on a person's health history and disabilities, is through an interview and assessment process."

The new tracking system will provide all the information needed to assess the medical magnitude of a person’s housing need without compromising their federally mandated health information privacy rights.

"When somebody is in a crisis, it's really hard for them to remember all the doctors they saw, how many appointments they had, what kind of medications they were on, and so forth," Hendges says. "It’s difficult to gather all of the information that's necessary to make a really good decision about what is the best housing intervention for them."

The U.S. Department of Housing and Urban Development (HUD) is the state’s largest funder of housing programs across the state for people experiencing homelessness. HUD requires housing agencies to prioritize resources to ensure that people who have significant physical or behavioral needs are connected with the housing that best meets those needs. However, determining each person’s distinct needs has been difficult based on the current assessment processes and data management system.

"There are lots of different varieties of housing and supportive services depending on what kind of support somebody needs," Hendges says. "Knowing that there's a lot of information out there that could be really useful in helping to make those prioritization decisions, we started discussing the concept of the medical vulnerability level."

The state’s current Homeless Management Information System (HMIS) matches data against Medicaid claims and utilization data to get a better idea of what the health landscape looks like for people experiencing homelessness. The data shows that, compared to the general Medicaid population, unhoused Michiganders are much sicker. The challenge comes in how to share the data in such a way that all housing agencies across the state can easily access it in individual cases. The new statewide indicator seeks to meet this challenge. Based on Medicaid history, claims, utilization data, electronic medical records, and additional criteria, people experiencing or at risk for homelessness will be assigned a level of medical vulnerability: high, medium, or low. Hendges says MDHHS hopes to pilot the system early next year.

"Our hope is that we'll be able to share those levels with our housing providers through the [HMIS] that the department has developed," she says. " ... All of these systems have multiple layers of privacy and security so that information stays protected."

As managers of Michigan’s HMIS, the nonprofit Michigan Coalition Against Homelessness (MCAH) links more than 650 Michigan homeless service agencies — emergency shelters, transitional housing programs, nonprofit housing and service programs, and government programs — to the data they need to operate effectively.

"In Michigan, we're fortunate because we can pull data for the entire state out of a single system. It makes data reporting and data analytics much easier in our world," says Gerry Leslie, Michigan State HMIS project director at MCAH. "A lot of the work that we're doing around social determinants of health is bringing together health care and homelessness."

MCAH reported that in 2019, 61,000 Michiganders experienced literal homelessness. More than 8,000 of these were older adults, 76% of whom lived with disabilities.

"The hope is really to reduce the rate of homelessness among those who are the most fragile and the most vulnerable, those we often find to be the hardest to serve," says Eric Hufnagel, executive director of MCAH. "The idea behind this is to take people who are considered to be more fragile and reduce that number so that we are able to ensure that some of our more vulnerable people on the streets or in shelters have permanent supportive housing with case management to ensure that they receive the services they need."

Overall, 66% of Michiganders experiencing homelessness in 2019 lived with significant mental health conditions, 43% with physical health conditions, 26% with substance use disorders, 25% with chronic health conditions, and 15% with developmental disabilities.

"These [numbers] are all significantly higher for seniors," Hufnagel says. "Whether it's substance abuse, mental health, HIV/AIDS, [or] chronic health conditions, it's higher in all those areas compared to the general population."

While the current HMIS system provides data on homelessness status, the new indicator will factor medical fragility into the equation, helping Michigan’s most vulnerable unhoused residents find places they can call home.

"There's going to be a five-point scale to show the degree to which medical fragility is there," Leslie says. "Somebody who is high on the homeless scale and also high on the medical vulnerability scale, you're going to take and prioritize them for accessing resources that may be permanent supportive housing and also health care resources and case management."

The indicator is designed to give agencies addressing homelessness a picture of the individual they are helping. For example, is the person going to be more appropriate for a first month's rent deposit, a rapid rehousing program, or an extended period of rental assistance? For those indicated to be more medically vulnerable, those with long-term disabilities that prevent them from working, those who have chronic illnesses, or older adults, options like permanent supportive housing with case management can ensure they receive the health care they need.

"It’s really about right-sizing the system and ensuring that people get access to the most appropriate housing resources based upon their condition," Leslie says.

Hufnagel says the program's long-term goal is to impact the incidence and duration of homelessness in Michigan.

"That's necessarily a quantifiable thing that we have a target for," he says. "But I think it's common sense that when you can address those issues more holistically, you're going to have outcomes that are better in both of those particular areas."

If you are currently experiencing homelessness and need assistance, call 2-1-1 and visit the MI Bridges website for additional resources. 

Estelle Slootmaker is a working writer focusing on journalism, book editing, communications, poetry, and children's books. You can contact her at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Lynn Hendges photos by Roxanne Frith.