At Montefiore Health System, a unique and impactful program is transforming how health care addresses 1 of the most significant social determinants of health: housing. Montefiore’s Housing at Risk Program (H@RP) goes beyond traditional medical care by offering essential support to patients who are homeless or at risk of losing their homes. Over the past 15 years, the program has evolved into a comprehensive support system that bridges the gap between medical care and social services. Oncology Issues spoke with Deirdre Sekulic, LCSW, associate director of social work at Montefiore and Kareemah Benbow, program manager for H@RP at Montefiore to learn more about the origins of this innovative program and its impact on patients’ lives.

The Beginning

H@RP was born over 15 years ago, in response to the frequent return of people who were unstably housed to Montefiore’s emergency department (ED). The team observed that many individuals lacked housing, resulting in prolonged hospital stays and an endless cycle of episodic care. “We saw these patients staying in the hospital for long periods, bouncing from ED to ED with no continuity of care,” Sekulic, one of the program’s leaders, recalled. “It wasn’t just that they were staying longer; it was that their care was disjointed and ineffective.”

In the early days of the program, Montefiore’s team began by analyzing the addresses given by patients during registration. When patients provided addresses linked to local homeless shelters or if they listed a doctor known to work with a high-risk population, these data served as a red flag that the patient might be facing housing instability. The team then collaborated with Montefiore’s information technology department to integrate these shelter addresses into the hospital’s registration system. This integration meant that if a patient provided an address associated with a shelter, an automatic alert would be triggered, notifying the Housing at Risk team in real-time.

“We started looking at high-utilizing patients who were coming into the ED without a stable place to stay,” Sekulic explained. “It wasn’t just about knowing where they were coming from; we had to figure out what was missing in the continuity of their care and what we could do differently.”

This early identification system expanded to include not just addresses but specific physicians who were known for treating vulnerable populations. If a patient did not provide an address or gave the address of a family member but mentioned a certain physician, the system flagged this scenario as a potential indicator of housing instability.

Additionally, as ICD-10 codes for homelessness were introduced, these codes were incorporated into the patient registration process. This multifaceted approach allowed the Housing at Risk team to build a robust database and trigger alerts when key indicators were identified.

An Innovative Approach

As do individuals affected by other chronic illnesses, patients with cancer often face barriers related to financial toxicity and insecurity. Sekulic stated, “When the head of a household is diagnosed with a chronic illness, like cancer, it can destabilize the entire family financially. We saw disability approval taking time, often leading to rental arrears that landlords weren’t willing to wait for.”

Kareemah Benbow, MPA, project manager, Housing at Risk Program, introduces a panel at the podium of the Housing at Risk 15th anniversary event.

Rather than simply referring patients to external housing resources, H@RP follows patients every step of the way. This support includes helping patients secure housing, assisting with benefits like Supple-mental Security Income, and even accompanying patients and family members to housing court or community service offices. This “boots-on-the-ground” approach ensures that patients regain stability and independence, with the support they need to navigate complex systems like housing and health care.

Benbow, who joined the team in 2021, underscored the program’s deep commitment to patient well-being, stating, “We stay with them through every step—finding housing, moving in, [and] making sure they feel secure.”

Respite Care Partnership

A key component of H@RP’s success is its collaboration with Comunilife, established in 2014. This partnership addresses the needs of medically fragile patients who cannot safely return to shelters due to ongoing care requirements, such as the need for intravenous antibiotics. Montefiore rents 4 respite beds, allowing patients to stay until they secure stable housing, to be able to extend their stay beyond the usual 90-day period if necessary.

Patients in the program benefit from a coordinated team, including a case manager, housing specialist, and social worker, who work with Comunilife to facilitate permanent housing and address medical needs. This partnership has helped more than 2 dozen homeless patients to transition to stable housing, ensuring continuity of their medical care. According to Benbow, “Respite offers a pathway to a safe discharge plan.”

This flexibility sets Montefiore apart from traditional hospital units. The Housing at Risk team works closely with patients in and out of the hospital, helping them access stable housing, essential services, and ongoing support.

Deirdre Sekulic, LCSW, associate director, Social Work, Montefiore Heath System (holding microphone), shares the history of the Housing at Risk Program.

Impact on Patients’ Lives

The true impact of H@RP is best illustrated through its success stories. One case involved a patient diagnosed with liver cancer who was significantly behind on his rent. The program’s strong relationship with the Department of Homeless Services enabled the team to secure funding and prevent eviction, allowing the patient to remain housed and stable during treatment. “He’d lived in the same apartment for over 25 years,” Sekulic recalls. “We were able to negotiate with the landlord and cover his back rent, which was over $20,000. He was able to stay in his home while undergoing treatment.”

In another instance, the team helped an elderly woman with cancer who had been sleeping on the floor of her church. She refused to enter a shelter, but the team collaborated with her church to improve her comfort while securing a one-bedroom apartment. “One of the things she told me was, ‘I just want to be in my own home, not in a hospital or a shelter,’” Benbow shares. “We were able to make that happen, and she passed away with dignity, surrounded by her family and friends in her own place.”

For many patients, newfound stability is symbolized by something as simple as a set of keys. Sekulic spoke of 1 patient who, upon receiving her first set of keys, refused to let go of them—even the ones that didn’t work. “She was so proud of those keys,” Sekulic recounted, highlighting how even small victories can represent profound change. “She had never had a set of keys in her life. It was like a symbol of security and independence for her.”

Benbow shared another memorable story about a patient in his 20s who had been homeless since he was a teenager. “He was [a person with diabetes] living under a bridge, and we finally got him into an apartment. When I called him the next day, he told me, ‘I didn’t sleep at all last night because I kept waking up, thinking this wasn’t real,’” she remembered. “He said the sounds of an apartment were so different from being outside—he had never experienced that before.”

Attendees at the Housing at Risk Program’s 15th anniversary event.

Future Goals

Looking ahead, Montefiore’s team plans to continue expanding H@RP. After a successful inaugural housing fair last year, the team plans to make it an annual event, offering consultations and resources to patients and community members alike. They are also exploring support groups, in which newly housed patients can mentor others, fostering a sense of community and shared experiences. Sekulic and Benbow are set to present their model and insights at national conferences, hoping to inspire similar initiatives in other across the country.

For health care institutions considering similar programs, Sekulic advises them to start small and focus on a specific patient population. “Start small and build,” she says, emphasizing that even modest beginnings can lead to significant growth over time.

Beyond Hospital Walls

Montefiore’s Housing at Risk Program stands as a testament to the power of a holistic approach to healthcare. By treating patients as whole individuals and addressing the root causes of their challenges, the team has redefined what it means to provide care. “We not only work with our patients, but we care about them,” Benbow reflected.

This commitment to compassion, flexibility, and community sets Montefiore’s program apart and serves as a model for health care institutions everywhere. It demonstrates that addressing social determinants of health is not just about improving medical outcomes but about restoring dignity and stability to patients’ lives.

Molly Kisiel, MSN, FNP-BC, is clinical director of Editorial Content & Strategy at the Association of Cancer Care Centers in Rockville, Maryland.

Oncology Issues extends its gratitude to Kareemah Benbow and Deirdre Sekulic for their invaluable contributions to this article and their ongoing dedication to the impactful work of Montefiore’s Housing at Risk Program.