The Difference Between Having Higher Acuity and Being Chronic

We continue to be overwhelmingly pleased with the expanded use of the Service Prioritization Decision Assistance Tool (SPDAT for short) and the VI-SPDAT as well. The more data that is shared with us from communities (made anonymous) the better. One of the very interesting things to observe is the small group of people in communities (has been less than 5% in the data that we’ve seen of all assessments, but in some communities making up more than a quarter of all higher acuity households) that have higher acuity, but DO NOT meet the HUD definition of chronic homelessness.

Maybe it is time to re-think our targeting efforts for programs based upon acuity level, not based upon eligibility of meeting a definition of chronic homelessness (or maybe we need to rethink the definition of chronic homelessness to include some consideration of acuity). If we don’t, some of the most unwell people on our streets and in our shelters will never meet eligibility criteria for some of the support and housing programs best capable of meeting their support needs because there are many Permanent Supportive Housing programs exclusively for chronically homeless persons – and in some communities ALL of the PSH is for chronically homeless persons.

 Acuity speaks to the severity of a presenting issue. In the case of an evidence-informed common assessment tool like the SPDAT, acuity is expressed as a number with a higher number representing more complex, co-occurring issues that are likely to impact overall housing stability.

Chronic by definition is something that has persisted for a long time. Furthermore, chronic is, by definition, something showing little change or extremely slow progression over time. In the disease literature, chronic refers to something lasting greater than three months in duration. In the parlance of HUD (though to HUD’s credit an evolving definition), chronic homelessness means one year of continuous homelessness or four episodes of homelessness in the last four years AND a disabling condition.

From purely a language perspective, I would argue there is greater utility in focusing on acuity as it lends itself to monitoring and measuring changes, whereas chronic is more stationary focused more on history and less on future. Chronic is backwards looking. Acuity is forward looking when changes in acuity are measured and monitored. Given the very nature of support programs that do the best work in supporting people with complex, co-occurring needs are hopeful in nature, acuity is better aligned to being peddlers of hope.

While most assessments are showing that people that meet the chronic definition of homelessness have more severe presenting issues (higher acuity), we need to start the discussion of how best to serve those that may be high service users, have a plethora of issues, be quite unwell, and would seem to benefit from the likes of Permanent Supportive Housing, but do not meet the federal definition. Some communities are doing more and more on this – but it likely warrants a more thorough policy and program discussion. If we don’t, three things will happen:

  1. prioritization through coordinated access will be limited/flawed because some of the people with the deepest needs won’t be eligible for existing programs;
  2. we will misinterpret our progress in ending chronic homelessness as a sign that the people with the deepest needs have the support and housing they need and deserve; and,
  3. we won’t ever truly end homelessness amongst some of the people with the most severe issues.

Iain De Jong

About Iain De Jong

2 Responses to “The Difference Between Having Higher Acuity and Being Chronic”

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  1. Gayl Killough says:

    I totally agree with you. Thank you for addressing this, I had been meaning to ask you about this. This is why I was troubled with the latest Continuum of Care application cycle put out by U.S. HUD. In order to gain points, local agencies felt forced to adopt the chronic homeless preference for permanent supportive housing. Why I think the intentions behind the strong emphasis on chronic homeless were well-intentioned, it ignored acuity. I was personally in favor of finding a compromise between chronic homeless and high acuity, but the local agencies could not adopt my compromise because it would have meant losing points in a competitive competition. It is HUD that needs to be convinced to adopt a preference for high acuity first.

  2. Amanda says:

    I completely agree with you on this as well. In the communities in which I have worked, they have all felt that HUD’s chronic homeless definition does not completely capturing the highest need (thus high acuity) and the definition HUD uses is not based on sound research or evidence. I advocated for NOT creating any additional chronic homeless PSH units, and instead just use an acuity score to prioritize people for housing. This method seems to accomplish HUD’s goals in a manner that is backed up by evidence…but as the above person commented, it would mean a CoC loses points in HUD’s competition. I hope HUD reads your blog!