Implementing the Quadruple Aim in Behavioral Health Care

Living Situation. This is measured as the proportion of people who live in permanent, supportive, stable housing; it may also be measured as the percentage of the population living with severe housing problems or who are homeless.

Brief review and suggested item(s). Housing problems can be conceptualized as 3 inter-related components: conditions within the home, neighborhood conditions, and housing affordability, each of which can contribute uniquely to poorer physical and mental health of individuals and families⁸⁴ and to educational outcomes for children.^85,86 Further, individuals who are homeless have a standardized mortality ratio 2 to 5 times that of the general population,^87-89 even after controlling for low income status,⁹⁰ and some evidence suggests these rates are even higher among unsheltered versus sheltered homeless individuals.⁹¹ Interventions to improve the condition of housing have demonstrated positive impacts on both physical and mental health,⁹² and a recent study found that individuals receiving housing assistance in the form of public housing or multifamily housing from the Department of Housing and Urban Development had better self-rated physical and mental health relative to individuals on the wait list for housing assistance.⁹³ Moreover, the provision of housing has been shown to promote reductions in substance use and health service utilization among homeless individuals with substance use disorders.⁹⁴ Rog and colleagues reviewed the literature on permanent supportive housing for individuals with substance use or mental health disorders who were homeless or disabled, and found that provision of housing led to reduced rates of homelessness, emergency department (ED) and inpatient utilization and increased consumer satisfaction.⁹⁵

Importantly, evidence suggests that housing is viewed as facilitative of recovery. For example, in a recent qualitative study of homeless individuals with mental illness, housing was seen as a critical first step in recovery, providing a sense of security, increasing feelings of personal independence and autonomy, improving perceptions of health and well-being, and affording a stable environment to rebuild relationships with important others.⁹⁶ BHD collects data on housing status on all the patients it serves as part of its state-mandated reporting requirements and will utilize this item in the CD data set.⁸³

Social Relationships. This is defined as recent interactions with family, supportive networks (formal and informal), and other recovery services.

Brief review and suggested item(s). Research has long established that social relationships have a significant impact on health, including rates of mortality as well as physical and mental health morbidity.^97-99 Social connectedness is another of the pillars supporting an individual’s recovery in SAMHSA’s formulation. Several reviews of the recovery literature^38,82 support its importance to the recovery process and inclusion in any assessment of holistic recovery. Social support has been shown to promote recovery among individuals with severe mental illness^100-102 and substance use disorders,¹⁰³ and may mitigate the progression of chronic, life-threatening physical illnesses.⁹⁷ For the purposes of BHD’s CD data set, the social support question from the “100 Million Healthier Lives Common Questionnaire for Adults” will be used to assess individuals’ perceived adequacy of social support.¹⁰⁴