Planners, policy makers, designers and managers prove how interdisciplinary multi-benefit solutions save money and time. We are also noticing how complex solutions impact that hardest-to-quantify constraint, quality. As I chew on the problem of securing the safety net one project at a time there is one thing of which I am certain. We all must figure out how to collaborate across disciplines in order to harness the value of these holistic solutions, and that these solutions can improve outcomes for all. This is especially true for the most vulnerable in our society and our world.
One of my long-standing beliefs is that specialization causes us all to overlook the interconnectedness of the social safety net. This is broadly shared amongst those that work in settings where the safety net fails citizens. In future posts, I will discuss the complexity of systems that shape that net and how it is continuously improved by both specialists and the administrative state. In order to set the stage for that discussion, I would like to first discuss some successful approaches to solving street-level problems at care settings. I have serious concerns that our systems aren’t flexible enough to meet the future challenges ARDS creates.
Much of this blog will be an attempt to mindfully, collaboratively bring my own passions and interests forward. It is intended to share my philosophy with friends and colleagues. The question of ‘as a planner, what do you do?’ is no longer just a cocktail party question about the role of a planner in the real world. Answering the question ‘what do you do’ is also more than the culmination of projects on a CV. It defines where you add value, what you hope to accomplish, and where you fit in the workplace.
One area in which I have been interested for years is the integration of housing and health care models. Just as there are continuums of care setting, there is an increasing need to use new tools and approaches that suit patients in a range of communities. This need requires the investigation of how to provide home-based care, how to align hub-and-spoke approaches to a range of built environments, and how ultimately to best pay for everyone to lead full and healthy lives. Critical questions to start with, I believe, is ‘how do we know if a setting works for its residents.
The conceptual model I prefer comes from Rudolf Moos ‘efforts to build a social ecological framework for analyzing treatment environments (1). His model is particularly useful because it is meant to compare and contrast both community-oriented and clinical settings.
There are alternatives to his conceptual model, Ann Wright and Kloos (2), Crook, et al.(3), and Rosenheck, et al. (4), but they all address interconnectivity between settings, residents, and outcomes. These alternatives give additional weight to what Ann Wright and Kloos call community level predictor variables by including available neighborhood data. This has a value, but the comprehensiveness of Moos’ approach and the availability of useful tools (go to: https://www.mindgarden.com/83-community-oriented-programs-environment-scale) allows for both comprehensiveness and consistency.
I also see direct interaction between outcomes and patient profiles with impacts like health service utilization and improved health. Moos illustrates the interaction between community adaptation and program characteristics. My using a conceptual model allows for a proven social environmental approach to understanding the relationship between program characteristics and patient profiles and their effect on the social climate, utilization of program services, and community adaptation. This social environmental approach should be considered for all types of places, spaces and communities. Assessments of the triple-bottom line should be consistent, and I believe we would benefit from shaping our approach to consulting based on work coming out of academia.
Why is this important?
The Lewin Group, for example, reports that the cost per day per person (pdpp) for supportive housing in NYC is about $41.00. Comparing this to Hospitals ($1185 pdpp), mental hospitals (467.00 pdpp), and even shelters (54.00 pdpp), provides evidence for the obvious value that supportive housing offers the system (5). While these numbers are old, they are also representative of social costs. Social Return on Investment (sROI) requires comparison for additional context, but it needs more than that. While it is obvious to many that frequent hospital care is more expensive than daily supportive environments, the costs must also be weighed against outcomes. A comprehensive model allows us to understand the impact settings have on individuals, just because an environment is cheaper does not mean it is right. But we must also shape the best outcomes in each setting, improve access to the most suitable settings, and allow folks to move freely when their needs change.
Work coming out of ProPublica, Frontline and the New York Times provides further evidence of how far we need to go in understanding what works in housing and care settings (6). Jacob Riis started this conversation for planners in 1889, but we would be remiss to think that our modern world has created safe spaces for our most vulnerable.
This is more than the question that mid-career consultants attack as we enter the marketplace, ‘do I become a specialist or a generalist?’. The answer we all know is… both! But in achieving work/life balance, it is hard to specialize in the way we could as we climbed the ivory tower. As we see every day on LinkedIn, specializations are best driven by personal passions. By day we may press for density (or at least we used to!), multi-modal transportation, and efficient city services. Our evenings, more-and-more, focus on gardening or fishing, our families and our communities. Many of my friends are planners by day, environmentalists at night. While those blend and mix together, it shapes our personal philosophies and subsequently our outcomes.
I am not a doctor or a health care administrator, and agree that assessments must be tweaked to meet the most current needs of a specific situation. But as we move forward with health care settings as a priority, it is important to play from the same sheet of music. I would be interested in which tools you use, or how they should be adjusted to deal with today’s shocks and stressors.
Photo by Matthias Zomer from Pexels
1 – Moos, Rudolf H.. (1997). Understanding Treatment Environments. (Second Edition). New Brunswick, NJ. Transaction;
2 – Ann Wright, Patricia, and Bret Kloos. Housing Environment and Mental Health Outcomes: A Levels of Analysis Perspective. Journal of Environmental Psychology 27.1 (2007): 79-89.
3 – Crook, Wendy P., et al. Outcome Measurement in Homeless Systems of Care. Evaluation and program planning 28.4 (2005): 379-90.
4 – Rosenheck, Robert, et al. Service System Integration, ACCESS to Services, and Housing Outcomes in a Program for Homeless Persons With Severe Mental Illness. American Journal of Public Health. November 1998, Vol. 88, No. 11.
5 – Lewin Group. (2004) Costs of Serving Homeless Individuals in Nine Cities: Chartbook. Partnership to End Long Term Homelessness.
6 – https://nytimes.com/2018/12/06/nyregion/nyc-housing-mentally-ill.html; https://www.nytimes.com/2020/04/08/nyregion/coronavirus-disabilities-group-homes.html