Assessment of Health for Housing Prioritization

Prioritization is at the center of affordable and supportive housing decisions. This is because resources such as these are extremely limited, and the needs of those who need housing support are complex. Communities must decide how to fairly and effectively determine who should receive housing opportunities first, and increasingly, those decisions rely on structured, coordinated assessments. While many tools exist to measure vulnerability and health, not all are well-validated or suitable for this purpose. This post provides an overview of the most widely used and validated health assessment tools, highlighting how they can support more equitable prioritization in housing systems. By summarizing what is available, the aim is to give communities and providers practical insights into approaches that may strengthen fairness and accuracy in the prioritization process. Navigating Affordable Housing Starts with Coordinated Entry and Prioritization The U.S. Department of Housing and Urban Development (HUD)’s Continuum of Care (CoC) program supports localized, geographically-bound communities in coordinating the many agencies and systems that have to work together with the goal of ending homelessness. CoC programs must establish coordinated entry systems to coordinate prioritization for services, including permanent housing, transitional housing, and supportive services for individuals and families experiencing homelessness. Increasing issues with the tools used for the assessment part of the housing prioritization process have created the need to explore alternative methods to improve current methods. Continuums of care across the United States develop and implement coordinated entry systems to streamline and centralize the process of connecting individuals and families to housing and services. At the heart of this process lies the coordinated assessment, which determines how needs are identified and prioritized. The assessment is crucial to prioritizing and matching individuals with the housing and services that fit their needs the most. Assessments help communities decide who receives housing opportunities first, ensuring that the most vulnerable individuals are not left behind. Yet, growing concerns about the reliability and fairness of existing assessment tools have prompted many communities to explore alternative approaches that better reflect people’s needs and circumstances. History of Vulnerability Indexes The construct of vulnerability has a long history of use in the assessment and prioritization of housing and services for homelessness in coordinated entry systems. The 100,000 Homes Campaign, advocating for Housing First, popularized this concept, and it is more predictive of mortality risk rather than housing support needs directly. Vulnerability-based assessments like the Vulnerability Index (VI) and the later released Vulnerability Index-Service Prioritization Decision Assistance Tool (VI-SPDAT), though widely adopted in practice in coordinated entry assessment, lack validation and reliability in use. Notably, OrgCode, which created the VI-SPDAT in 2013, always intended it to be a pre-screening tool rather than a standalone tool for determining housing priority. In 2020, the tool’s creators announced their decision to phase out the use of the tool for this purpose. They cited differences in survey administration methods across communities and instances where the tool wasn’t being used in the intended manner. This tool also reinforces disparities in scoring by race, gender, and ethnicity. Due to the increasing shortcomings in this popular tool, a need to shift to a new tool for assessment arose. Expanding on the idea of vulnerability incorporates concepts like frailty, comorbidities, and quality of life. These concepts open the door to adapting validated assessment tools that give a fuller picture of health. Such tools can help communities better connect health needs with housing prioritization. None of the following tools or concepts have been validated specifically for homeless populations. However, they provide a strong starting point for communities to explore, adapt, and improve their assessments. In reviewing tools, we focused on two criteria. First, the tool needed to cover three domains of health: physical, psychological, and social. Second, it had to be validated for accuracy in measuring health needs. Frailty We began our search with the concept of frailty and frailty-based instruments. Frailty is a measure mainly used for older populations and looks at a person’s functional status. One frailty-based tool that stood out was the Tilburg Frailty Indicator (TFI). The TFI survey uses self-reported measures and considers physical, psychological, and social domains of health. The survey has two parts, with the first part looking at determinants of frailty (demographic and lifestyle factors). The second part looks at components of frailty (physical, psychological, and social domains). This instrument’s scores range from zero to fifteen, and a score greater than five indicates that an individual is frail. Similar to other frailty-based surveys, this tool is primarily for use in older populations since its creation. Pros: Thorough: covers physical, psychological, and social domains; quick to administer; it has predictive validity Cons: The validation and use are limited to older populations since its creation. Although this tool covers the domains of health we’re interested in, along with it being validated, the fact that it has only been used in older populations presents a clear limitation. Comorbidity/Disease Burden Comorbidity indexes are tools to measure comorbidities using ICD-9 and ICD-10 codes for health conditions. These tools only cover the physical domain of health and lack the social and psychological domains of health, which makes them more limited than the other tools discussed. Additionally, these tools have mainly been used in hospital-based populations. They are only validated to be predictive of in-hospital mortality. Common comorbidity indices include the Charlson Comorbidity Index (covers 19 health conditions) and the Elixhauser Comorbidity Index (covers 30 health conditions). An important issue with using an index for assessment is that indexes typically do not consider the severity of conditions or factors in the assessment. They only provide a count of the issues. Using a scale instead accounts for the severity of each factor. The VI and the VI-SPDAT surveys also have this issue, as they are both indices. Pros: Predictive of mortality (in-hospital), incorporates the use of hospital medical records (non-self-reported measures – more objective) Cons: Only physical domain; limited to hospital-based populations Looking at comorbidity indices, all the reviewed tools give a more in-depth look at the physical aspect compared to other tools. Quality of Life Finally, we looked at tools based on health-related quality of life (QOL). The CDC defines this concept as “an individual’s or a group’s perceived physical and mental health over time.” The SF-12v2, CDC-HRQOL-14, and the EQ-5D-5L are three tools that stood out. SF-12 v2 The 12-Item Short Form Survey (version 2) (SF-12v2), derived from the longer SF-36, includes eight health concepts: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. The results create two composite component scores: the physical component summary score and the mental component summary score. This tool covers physical, psychological, and social health domains, providing a well-rounded summary of health. Researchers have validated it for use in specific patient populations, including diabetic and older populations. The SF-12 (version 1) has been used in homeless populations and was shown to have some construct validity; however, it was only studied in a small sample size. Pros: Covers physical, social, and psychological domains; short and easy to administer Cons: Only validated in limited populations HRQOL-14 Next, the CDC’s Health-Related Quality of Life (HRQOL-14) survey tool focuses on physical and psychological domains but lacks the social domain. This survey uses a question set called the “Healthy Days Measures“. The questionnaire has three sections: the core module, the activity limitations module, and the healthy days symptoms module. The activities limitations module is particularly relevant as it takes into account the duration and degree of disability or activity limitation, reminiscent of the frailty-related tools that take into account functional impairments. Plus, it calculates a summary index of unhealthy days (an estimate of the number of days in the last 30 days where physical or mental health was not good) from the results. Healthy days derive from subtracting the number of unhealthy days from 30 days. Notably, this is a continuous measure rather than a categorical measure (number of days instead of categorizing health status). Both the Behavioral Risk Factor Surveillance System (BRFSS) and the National Health and Nutrition Examination Survey (NHANES) questionnaires use this measure nationally. This tool is both reliable and valid. Pros: Short and easy to administer, self-reported measures, validated in the general population Cons: Lacks social domain EQ-5D-5L The final quality of life tool is the EQ-5D-5L (EuroQol). This survey instrument only has the physical and psychological domains and does not consider the social domain. It has five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension has 5 levels of severity (as opposed to the earlier version developed, EQ-5D, which only assessed each dimension in 3 levels of severity). Each dimension asks for a description of the respondent’s health on the response date. The level of severity ranges from 1 to 5. Respondents can also self-rate their health on a scale of 0 to 100 (called the EQ-VAS), with 100 being the best health you can imagine and zero being the worst. In this way, EuroQol includes the respondent’s perception of their own health status and responses to the survey questions. A benefit to using this tool is that it measures severity rather than just an index (i.e. count) of conditions that someone has. That makes it a more accurate measure of the quality of life. Additionally, the developers designed it for the general population (unlike many frailty tools, which are developed primarily for older populations). And there are both adult and youth versions. This tool shows convergent validity. Pros: Short and easy to administer, self-reported, measures severity, can be administered in multiple methods (paper, digital, interviewer) Cons: Lacks social domain HR-QOL based tools give the broadest view of an individual’s health and functional status of the three concepts, though some tools are missing the social domain. Like frailty, they focus on functionality which is important to consider during the housing prioritization process. Unlike frailty, however, these tools are more applicable to broader populations. Conclusion Most of the tools included (with the comorbidity indices as an exception) rely on self-reported measures. This presents a unique issue in capturing health history in its own right. This is especially true for instruments like the CDC’s HRQOL-14 instrument, which relies on self-reports covering the previous 30 days. Entries into homelessness may have occurred in less than the last 30 days, which may make the assessment less reliable in assessing health during homelessness. On the other end of the spectrum, for tools like the EQ-5D-5L, which ask about health in the moment, health status on a single day might not be indicative of the health of an individual on the whole. All communities can choose and develop their own assessment tool and prioritization process for their coordinated entry system. Currently, communities are not required to use any one assessment tool for their coordinated entry system. This lack of standardization and guidance around an assessment tool creates obstacles for communities to have an effective housing prioritization process. However, by investigating existing validated instruments from other health sectors, we can develop relevant tools for our communities to improve existing systems.