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.

Priority Lists, Not Waiting Lists

Let us put an end to waiting lists for housing (or – gulp – shelter for that matter).

Let us replace those lists with priority lists.

Waiting lists, with some exceptions, are not designed to serve those with the deepest needs. They are designed to serve those that have waited the longest. But here’s the thing – if I have really deep needs it is entirely possible that I will die before my time comes up on a waiting list.

Imagine if emergency rooms took the waiting list mentality. Last night, Sally stubbed her toe. She goes to the ER and is told by triage that there is nothing they really do for a stubbed toe and that she should go home. Sally insists on waiting. This morning, around 6am, Bernie sliced his finger while making breakfast. He goes to the ER. Triage tells him they aren’t sure if he is going to need stitches or not. They bandage him up. They tell him to take a seat until a doctor becomes available. They tell him that if anything changes or gets worse, to come back to the triage window. Fred had a heart attack at 9am.

Sally is still waiting.

Bernie is still waiting.

Who gets served next?


But why? Haven’t Sally and Bernie been waiting longer? Yes they have. But Fred’s needs are more acute than Sally and Bernie. If you don’t serve Fred right away he may die. Bernie can wait a little bit. Sally, well, she may want to be served and be willing to wait all day, but she doesn’t really need the ER services.

In just about every scenario, a reasonable person would expect the person with the most urgent needs to be served next. Except that isn’t how we tend to operate affordable housing, supportive housing, or intensive support programs. Even when there is modified chronological access (a fancy term for being able to jump the queue a little bit), it is rarely based upon acuity in its totality, but rather preference for a priority population that may not be grounded in evidence.

In an era of better assessments of client needs and coordinated access, I want you to rip apart your waiting lists. Delete them from your computer. Replace them with a priority list. Triage access to housing based upon who has the highest priority for that housing and the supports that come with it. Don’t manage access by who has waited the longest. That has nothing to do with who needs it the most.

Assessment & Prioritization Tools: What to Look For

Is your community trying to move towards common assessment as part of coordinated access? You should be. In response to inquiries from a few avid blog readers (thanks!) here are some questions you should ask when your organization/community is choosing an assessment and prioritization tool. 1. Is it grounded in evidence? There is no shortage of ideas on what may be a good thing to assess when a homeless person or family seeks services. Unfortunately, too many communities come up with their own list (sometimes LONG list) of things to assess without those ideas actually being grounded in evidence of what works, and the main currents of thought and practice in service delivery. That which we think and that which we know are often two totally different things. Your assessment tool should be grounded in knowledge and data, not unsubstantiated thoughts or feelings. 2. Has it been tested? Given the […] Read more »

Using Data to Drive Program Improvements

PART SIX: Using Data to Drive Program Improvements Data. I know it is a four-letter word. It makes policy wonks salivate lustfully and makes many front-line practitioners run for the hills (or the bottle). Truth is, data doesn’t have to be scary or cumbersome or a nuisance. Done right, data is the ace up your sleeve to make your program transition from good to great. As a starting point, know that there are resources out there that can help you if you are unfamiliar or uncomfortable with data. The National Alliance to End Homelessness has a range of nifty resources. I especially like What Gets Measured Gets Done. Data and performance measurement is also a subject matter I get asked to speak about a lot. So, if you want to check out some of that – littered with “Iain-isms” – feel free. Plus there are a few previous blogs (not […] Read more »

Appropriately Using Assertive Engagement

So you have a client that has engaged in case management supports with your organization, but they never seem to be around or seem completely unengaged when you do meet. They have high acuity. They likely have several complex issues and have experienced long-term homelessness. Is the fact that they are rarely around or seem completely unengaged sufficient to “cut them loose”? Should your organization move on to another person who is more eager to actively participate in what you have to offer? No. In this blog I talk about how to use assertive engagement appropriately to first engage with people who have accepted case management services and then become unengaged, as well as how to effectively engage with people who are homeless and do not seem interested in having a conversation about housing and case management. In a perfect world – heck, even in a lot of “normal” therapeutic […] Read more »

Prioritizing Who Gets Served Next Matters – The Service Prioritization Decision Assistance Tool (SPDAT)

When I led the largest Housing First program in North America, one of the things that bothered me was that we had no defensible way to prioritize who we served next. We dabbled with different instruments and had some stellar research thanks to folks like Toby Druce – but couldn’t quite put our finger on exactly how to prioritize who got served next and why. At least not in a defensible, reliable, consistent and valid way. Sure, there are some awesome instruments out there like the Vulnerability Index used by Common Ground and now the 100k Homes Campaign (and we are big fans of both); the Camberwell Assessment of Needs; the Outcome Star; the Denver Acuity Scale. But none of these were a perfect fit for the type of Housing First program that I was leading or other Housing First programs that I was familiar with. One of the first […] Read more »