Envisioning Housing Equity: A Framework to Promote Housing Security Among Hospitalized Children

Insecure housing is a significant problem amidst a multifaceted housing crisis in the United States. There are many contributing factors, including high housing costs, short supply of homes, and stagnant wages among lower- and middle-income households in the broader context of structural inequities and sociopolitical forces that have shaped housing circumstances.1–3 Some examples of housing insecurity range from individuals residing in overcrowded conditions, to those experiencing multiple moves, eviction, or the most extreme case of homelessness. Homelessness reached record high levels in 2024, and the number of people in families with children experiencing homelessness increased by nearly 40% compared with the prior year.1Considerable evidence indicates that housing is a key driver of health, and the adverse impact of inadequate housing on child health and developmental outcomes is well established.4,5 Housing warrants additional attention given its complexity, role in the development of health disparities, and association with hospitalizations as described below. We highlight housing as an important domain to further examine as the field of social care integration gains momentum in the inpatient setting and as hospitals navigate how to develop, implement, and evaluate their strategies. In the current landscape, individual hospitals that are screening for social needs are assessing variable social domains, and studies to date have been limited to examining feasibility, acceptability, and preliminary effectiveness.6In turn, we propose a framework for supporting housing security among hospitalized children, and one that extends beyond the steps of screening and referring. This is conceptualized as a logic model in Figure 1, which supplements the manuscript with additional details.Although there are many studies about addressing housing needs among children in the primary care setting, housing insecurity has been minimally examined in the pediatric inpatient setting.7–9 The hospital is an important space to leverage because children affected by insecure housing often receive health care services inconsistently and are more likely to be hospitalized compared with their stably housed counterparts.4,10,11 Therefore, the hospital encounter offers a unique opportunity to reach families in precarious housing circumstances and to address both medical and housing needs using a family-centered approach.Housing insecurity can also impact a family's ability to provide adequate posthospitalization care, which could inform management decisions or potentially extend the length of stay. For example, a family may not have the ability to store refrigerated medications required after discharge or regularly access electricity to operate a nebulizer machine at scheduled intervals. Furthermore, the disruptive nature of a hospitalization can further worsen a family's socioeconomic strain related to the challenges with experiencing and recovering from illness. In fact, the burden of a hospitalization itself is associated with greater likelihood of subsequent housing hardships among underresourced families.12 These points underscore the importance in timely recognition of housing needs before reaching a crisis point of being displaced or unhoused.The overall approach to addressing housing insecurity should be tailored for each hospital based on their local needs, community assets, and response capabilities. Hospitals can start with an environmental scan of their catchment area to determine general community needs. For nonprofit hospitals, there are existing community health needs assessment requirements, and evaluations conducted by public health agencies may be used as well to determine high-impact priorities.If housing insecurity is recognized as a significant issue, an evaluation of community resources can be performed to understand availability and capabilities to adequately respond to patient needs. These resources could include local housing authorities, shelters, tenant organizations, and other housing advocates. Hospitals can also learn from primary care practices since many may have existing knowledge of and experience working with various organizations. Hospitals should then establish or build on these relationships to foster effective partnerships. This approach should also be accompanied by gaining understanding of the community members' trust and views about the resources to ensure successful connection and follow through with future referrals.If housing insecurity is not found to be a priority issue, hospitals could adapt our framework for other health-related social needs relevant to their community. The framework was developed specifically for housing due to its innate complexities, challenges, and association with hospitalizations, but with the broader intent that additional needs could later be integrated over time since housing insecurity often intersects with other social risks.As the pathway to recognizing and responding to housing insecurity in the inpatient setting is being explored, the topic of housing could be integrated into the existing infrastructure of the discharge planning process, which offers a natural entrance into a conversation about housing. This method would circumvent the challenges of building a new process and minimize workflow disruptions in a busy clinical environment. Although health care providers would require education, enhancing a known practice would involve less training to implement compared with administering a new instrument, for example.Since discharge planning starts on admission and is a built-in component of the daily plan, the structure provides set opportunities to identify housing-related barriers and the ability to use time during the hospitalization to coordinate any desired services. Recognizing housing needs inherently becomes a shared responsibility and expectation for the entire care team rather than a task designated to a specific person, which could result in inconsistent practices and perpetuate inequity. Importantly, this approach captures all patients and at multiple touchpoints throughout the hospitalization.The topic of housing would become standardized and normalized over time, which would ideally remove the perception of marginalization or the possibility of implicit bias by ensuring the subject is discussed with all families. Furthermore, by directly connecting housing circumstances to the medical aspects of the hospitalization or postdischarge care, it might neutralize some of the vulnerabilities with disclosing this type of sensitive information and potentially elicit more candid responses. Privacy should be offered when entering these discussions, and health care teams should also respect a family's preference to decline sharing this information.Hospitals could start the process with a hospital medicine team and gradually scale efforts to include other service lines over time. This method would ensure that both hospital and community-based services have the ability to assist families as they build capacity and avoid overwhelming either system. Additionally, it would contribute to safeguarding against disproportionately redirecting resources away from other households in the community. There would need to be linked mechanisms in place for incorporating ongoing feedback between the hospital and community-based organizations to ensure effective, adaptive, and sustained implementation.With the growing shift toward value-based models and national regulatory bodies now incentivizing the use of health-related social needs quality measures, hospitals should invest in building robust multidisciplinary teams to support these changes.13,14 The teams could include quality improvement personnel as well as those who have an understanding of and ability to foster connection to benefit programs and resources, such as social workers, case managers, community health workers, and medical-legal partnerships. Medical-legal partners are uniquely skilled with their understanding of housing laws and can facilitate eviction hearings or assist with landlords who may not be maintaining a safe and habitable home. For hospitals with limited resources, physician-generated letters to landlords can be a simple and effective method to remediate poor housing conditions.15 These letters can be templated and integrated into the electronic medical record allowing for an immediate intervention.It should be a strategic priority for hospitals to invest in the upstream drivers of health to generate structural changes. These are necessary steps to mitigate the lasting effects of historical redlining and exclusionary practices, unequal housing opportunities, and longstanding disinvestment in marginalized communities. Hospitals should advocate for equitable housing programs and policies at all levels of government to promote stable, affordable, safe, and quality housing. For example, some states are leveraging their Medicaid waivers for temporary rental assistance and other housing-related supports. Additionally, nonprofit hospitals are required to meet the community benefit standard and could use their spending by investing in local housing agencies and supporting community development efforts, such as building affordable housing units or renovating neighborhoods with deteriorating housing stock.Hospitals can assess the effectiveness of their various strategies by not only measuring outputs but also measuring outcomes. Hospitals could start with examining rates of housing assessments, identified needs, social work consults, and community referrals. Importantly, it is essential to extend beyond this step and gather data after discharge, such as evaluating connections with resources and subsequent improvement in families' housing circumstances. Over the long term, hospitals could analyze health care utilization, including readmissions, health care costs, and child health outcomes. These data are necessary to monitor the impact and progress of interventions and to better align hospital strategies.All of these efforts will require notable investments in planning, training, and operationalizing. Hospitals with limited assets, such as small community hospitals or those located in rural settings, will inherently face more challenges. They could consider establishing a partnership or affiliation with nearby children's hospitals or primary care networks to access more support with infrastructure and services. Hospitals with extensive catchment areas will likely encounter variable needs and resources, and can strategize their approaches based on their most pressing demands and ability to mitigate gaps. Ultimately, hospitals can design and build toward a system that works for their local environments.As childhood housing insecurity remains an ongoing problem throughout the country and one that requires multisector collaboration among stakeholders, it is important for hospitals to create pathways to be part of the solution. Housing is a critical vehicle for good health, and supporting secure housing among hospitalized children can be one key branch of a broader strategy to reduce health inequities and build healthier communities.