Rethinking Housing Prioritization: A Search for Better Health Assessment Tools
The urgent need for affordable and supportive housing demands a fair and effective system for determining who receives assistance first. Increasingly, communities are turning to structured assessments to prioritize individuals experiencing homelessness, but concerns about the reliability and equity of existing tools are growing. This article provides an overview of validated health assessment tools that could strengthen prioritization processes and ensure the most vulnerable receive timely support.
The U.S. Department of Housing and Urban Development (HUD)’s Continuum of Care (CoC) program plays a critical role in coordinating housing and services at the local level. CoC programs are required to establish coordinated entry systems, but challenges with assessment tools have spurred a search for improved methods. “Assessments are crucial to prioritizing and matching individuals with the housing and services that fit their needs the most,” highlighting the importance of accurate and equitable evaluation.
The Limitations of Existing Vulnerability Indexes
Historically, vulnerability indexes like the Vulnerability Index (VI) and the Vulnerability Index-Service Prioritization Decision Assistance Tool (VI-SPDAT) have been widely used. However, these tools lack robust validation and have been shown to reinforce existing disparities. OrgCode, the creator of the VI-SPDAT, announced in 2020 its intention to phase out the tool for prioritization purposes, citing inconsistent administration and unintended biases related to race, gender, and ethnicity. This decision underscored the need for alternative approaches that provide a more comprehensive and reliable picture of an individual’s needs.
Expanding the concept of vulnerability to include frailty, comorbidities, and quality of life offers a promising path forward. By adapting validated assessment tools from other health sectors, communities can develop more nuanced and effective prioritization systems. A key focus in evaluating these tools was whether they covered the three core domains of health: physical, psychological, and social, and whether they had been validated for accuracy.
Exploring Alternative Assessment Tools
Frailty as a Measure of Functional Status
Frailty, typically used for older populations, assesses an individual’s functional status. The Tilburg Frailty Indicator (TFI) stands out as a tool that considers physical, psychological, and social domains. The TFI uses self-reported measures and provides a score ranging from zero to fifteen, with a score above five indicating frailty. While thorough and quick to administer, its validation is currently limited to older populations, presenting a challenge for broader application.
Comorbidity Indexes: Focusing on Physical Health
Comorbidity indexes, such as the Charlson Comorbidity Index (covering 19 conditions) and the Elixhauser Comorbidity Index (covering 30 conditions), measure the presence of multiple health conditions using ICD-9 and ICD-10 codes. However, these tools are limited to the physical domain and primarily validated for hospital-based populations, predicting in-hospital mortality rather than housing needs. Furthermore, they typically only count conditions without considering their severity.
Quality of Life Tools: A Holistic Approach
Tools based on health-related quality of life (QOL) offer a more holistic view of an individual’s well-being. Several tools emerged as particularly promising:
- SF-12v2: Derived from the SF-36, this 12-item survey covers physical, social, and psychological domains, providing a well-rounded assessment. It has been validated in specific populations, including diabetic and older adults, and demonstrated some construct validity in a small study of homeless individuals.
- CDC-HRQOL-14: Developed by the CDC, this tool focuses on physical and psychological domains, utilizing “Healthy Days Measures” to assess the number of days with impaired health. It is reliable, valid, and validated in the general population, but lacks a social domain component.
- EQ-5D-5L: This survey assesses mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, with a severity scale for each dimension. It also includes a self-rated health scale. The EQ-5D-5L measures severity rather than simply counting conditions and is designed for the general population, showing convergent validity.
Quality of life tools, unlike frailty measures, are more broadly applicable to diverse populations and emphasize functionality, a crucial consideration in housing prioritization.
Challenges and Future Directions
Most of the reviewed tools rely on self-reported measures, which can be problematic when capturing health history, particularly for individuals recently experiencing homelessness. The timing of assessment is also critical; assessments relying on the past 30 days may not accurately reflect an individual’s health status if their homelessness is recent.
Currently, communities have the flexibility to choose their own assessment tools, leading to a lack of standardization. “This lack of standardization and guidance around an assessment tool creates obstacles for communities to have an effective housing prioritization process,” one analyst noted. However, by leveraging validated instruments from other health sectors, communities can develop more effective and equitable systems.
Further research is needed to adapt and validate these tools specifically for homeless populations. A standardized approach, informed by rigorous evaluation, will be essential to ensure that housing resources are allocated fairly and effectively to those who need them most.
