Community Health Workers Confront Missoula's Housing Crisis
These vital public health workers do all they can to support local residents facing barriers to housing.
I don’t have time for my morning routine. The Pov is scheduled for a sweep today.
It was Thursday, June 22, 2023. A homeless encampment on Cedar Street outside of the Poverello Center (the Pov), one of Missoula's homeless shelters, was slated to be cleared out, with city officials citing health and safety concerns . Earlier in the month, then-Mayor Jordan Hess had declared a state of emergency over the houselessness crisis in Missoula. The sun was rising and the clock was ticking.
Cedar Street, Missoula, MT
Early in the morning, community health workers, Partnership Health Center’s (PHC) Community Care Team, and other community partners arrived at the camp. Outreach to Missoula’s unhoused population has been a healthcare priority and a focus of PHC's community health worker (CHW) program, which launched in 2021.
Today’s challenge was to help people pack and relocate as many of their belongings as they could manage. The energy was hectic as residents rushed to pack up life essentials, medications, and cooking supplies.
I was told that if folks were not moved by 10, the cops would start arresting them.
This was not the first time the Cedar Street encampment had been cleared, but unlike previously, the area would remain closed off while the nearby YWCA underwent deconstruction. This time, everyone in the encampment would have to stay gone.
All residents of the encampment would have to find somewhere else to go. However, there were limited options available. The city's Authorized Camping Site was closed in October 2022 . The Johnson Street Winter Emergency Shelter was closed for the summer season and would not reopen until later that summer as a Temporary Emergency Shelter. Some would choose to relocate to nearby Downtown Lions Park around the corner on California Street. However, this park was scheduled to be cleared the following week.
There was a sense of panic amongst the people we were helping. As they asked over and over, “Where are we going to go?” we had no answers.
Once the clock struck 10, the encampment was cleared. No arrests were made during the sweep. After everyone was moved, bulldozers collected what remained. The street cleaners were the last to work their way through the vacated lot.
We helped move 16 tents to safety. Ultimately, bulldozers were brought in to demolish our clients' homes. Bikes were bulldozed as they couldn't get moved fast enough.
Cedar Street, behind the Pov (right), May 2024
Our clients are sad and don't understand how someone could take away homes.
With the encampment dispersed, CHWs and other local service providers did what they could to provide emotional and tangible support to the community members impacted by the sweep.
I went to the foodbank for all of the people we moved this morning. I found bike locks to replace the locks that were cut in haste. Most everyone was happy to receive the food.
One CHW felt the support they offered was meager in the face of what they had just witnessed.
I don’t feel like I accomplished anything today. I literally showed up and watched peoples’ lives change.
This composite recollection of the day's events from the perspective of CHWs illustrates Missoula's ongoing housing crisis and the complexities of supporting residents it has displaced.
Missoula's Housing Affordability Crisis
Across the United States, housing unaffordability has reached an all-time high, with half of all renters spending more than 30% of their income on rent and a record number of people experiencing homelessness. Missoula is no exception to the housing crisis; the COVID-19 pandemic, coupled with population increases and a lack of affordable housing stock, have put a major strain on the housing economy. While the City continues to look for solutions to the housing crisis, local organizations and service providers, such as CHWs, have stepped in to help residents navigate existing housing resources.
A Decade of Rising Costs
Missoula housing costs have dramatically increased since the start of the pandemic. In 2019, the median Missoula home cost $310,000. Four years later, the median cost was $530,000 – a 71% increase. 40% of renter households are cost-burdened (spending over 30% of income for rent and utilities). According to County Health Rankings & Roadmaps data from 2016-2020, 16% of Missoula County residents experience severe housing problems such as high cost burden (spending over 50% of income for rent and utilities), overcrowding, or lack of kitchen or plumbing facilities.
Sources: US Department of Housing and Urban Development, Missoula Organization of Realtors
Rental availability has also been a prevailing issue in Missoula. Since 2012, only four fiscal quarters have had a rental vacancy rate above the minimum healthy 5%. The vacancy rate bottomed out in 2022 at 0.4% before bouncing up to 4.4% the next year. Low-income housing options have also been strained, with applicants waiting up to 4 years before receiving a Housing Choice Voucher according to the Missoula Housing Authority. The voucher wait list reached a record 1,816 people in 2023.
As a consequence of increased housing costs and decreased housing availability, homelessness in Missoula peaked at an all-time high of 812 people in January 2023. The Missoula unhoused population makes up approximately 30% of all Montanans facing homelessness.
Missoula Community Health Worker Program
Missoula CHW Partnering Organizations
In 2021, PHC, Missoula's federally qualified health center, received $1.8 million in funding from the Centers for Disease Control and Prevention (CDC) to hire CHWs to reach Missoula residents that are underserved and people who face systemic barriers to accessing program needs and services. This funding enabled the creation of seven new CHW positions across PHC and two other partnering organizations, Missoula Public Health (MPH) and All Nations Health Center (ANHC).
CHWs play a pivotal role in bridging gaps, promoting health equity, and empowering community members to achieve their goals. The CHW role is rooted in the idea that those who have lived experience with complicated healthcare and social systems are in the best position to help others navigate those systems.
Missoula CHWs focus on reaching unhoused and economically marginalized residents and families by meeting clients where they are at and coordinating services with other local organizations. Since the program began in 2021, several CHWs have worked closely with housing resources such as the Pov, Blue Heron Place, and Missoula Housing Authority.
Housing as Healthcare
Housing is a key social determinant of health . The affordability, accessibility, and quality of housing in an area can have major impacts on community members’ health and well-being. Poor quality housing can contribute to injuries and result in health issues through exposure to mold, lead, or asbestos, while the strain of struggling to pay for housing is linked to chronic disease and poor mental health. Poor health can then lead to challenges with maintaining employment and, ultimately, housing.
According to a 2022 report by CityHealth , “poor health – particularly for low-income renters spending more than 30% or more of their household income on rent and utilities – can quickly lead to the non-payment of rent, the foremost reason for eviction in this country.” Access to safe, quality, affordable housing is fundamental to sustaining good health.
Unhoused community members face even greater barriers to health and are more likely to have a disability or conditions such as diabetes, heart disease, HIV/AIDS, or chronic substance abuse than those with housing. Accessing healthcare while navigating homelessness is difficult; people experiencing homelessness are often focused on meeting their basic needs, may not have reliable transportation to attend appointments, and may have inconsistent access to phone and internet services necessary for scheduling and communication with providers.
In this position, I have come to realize there is so much to do, to help understand, connect, to reassign agency. The person knows what they need but there is a point where they are unsure of how to access the resource.
CHWs in Missoula are working to connect clients to healthcare and overcome barriers to health. However, stable housing is often one of the most pressing needs of their clients and resources for housing and shelter are limited. Scroll through the map below to read about challenges and successes of CHWs in trying to navigate Missoula’s housing crisis.
Partnership Health Center
To support clients in accessing needed healthcare, CHWs often accompany clients to medical appointments. One PHC CHW went to meet and accompany an unhoused client to an appointment. The client had last been known to be staying at an encampment near the Poverello Center.
Upon arriving at the camp, the client was nowhere to be found. The CHW received a tip that they had moved across the river. Two phone calls to the client did not go through. In hopes that the client had made it to the appointment alone, the CHW called the healthcare provider, only to learn the client had not arrived.
The CHW wrote:
"This is a classic instance of housing as healthcare. I knew where this patient was staying 6 days ago and confirmed the appointment over the phone, when she had a place to keep it charged and connected to Wi-Fi. In the intervening 6 days, the patient moved her camp, likely losing access to Wi-Fi, therefore becoming unreachable."
The Poverello Center
Managing homelessness, health issues, and social isolation can make getting out of or staying at the Poverello Center difficult. For one young unhoused person with mental illness who was living at the Pov, a CHW became a lifeline of trust and support during a particularly vulnerable time.
After working with the CHW for several months while living at the Pov, this client left the state, but returned when they became pregnant. With no other family or social support in place, the CHW took the lead in overseeing prenatal care for their client. The CHW arranged appointments with the PHC obstetrics coordinator, accompanied the client to appointments, and secured baby clothes, a car seat, and a playpen for the client.
Because the client was still living at the Pov, the CHW stressed the importance of finding more stable housing. The CHW was eventually able to help the client and their partner secure family housing at YWCA Missoula.
As a “ recovery doula in training” through Montana’s One Health/Tree of Life program, the CHW was also able to offer the client free doula services. The CHW accompanied the client to the hospital when they were induced and stayed throughout the labor and delivery, addressing barriers to communication with healthcare providers and supporting the client. The CHW remains in close contact with this client, strategizing together to optimize the quality of life for the young family.
Blue Heron Place
Blue Heron Place (BHP) is a permanent supportive housing initiative born of a collaboration between the city, county, PHC, the Pov, Missoula Housing Authority, and the nonprofit Homeword. It is a part of the larger multi-site Trinity Apartments and focuses on providing additional support for people with difficulties retaining housing.
BHP opened in September 2023. By mid-December, all 30 apartments were full, housing 33 people. Each apartment comes with rental assistance vouchers, so only 30% of tenants’ monthly adjusted income goes towards rent and Missoula Housing Authority pays the rest. The vouchers work even for residents with no income.
PHC provides staff for BHP during the day, including tenancy support specialists and a CHW. Workers from the Pov staff the building at night. With staff around to provide support for residents, they are able to have the stability needed to remain housed.
Missoula Public Health
When clients were signing a lease for a new home, their CHW helped communicate details and performed a walkthrough of the property. Upon seeing the poor condition the home was in, the CHW took the lead in documenting and photographing every problem.
The property manager received the documentation and complaint about the home from the CHW.
Missoula Housing Authority
Efforts to secure income-restricted housing and housing choice vouchers, formerly Section 8, require coordination with the Missoula Housing Authority (MHA).
When MHA indicated that Native American residents were disproportionately at risk of losing their housing due to not renewing their housing vouchers, CHWs from ANHC and MPH met with MHA to problem-solve. They found that MHA's notices and reminders about annual recertification often did not receive responses.
The CHWs began meeting with clients to help them address barriers and anxieties related to the recertification process and work through the process with them. Immediately, one CHW was able to keep four families housed.
Sustaining Community Health Worker Support of Local Housing Needs
The work that CHWs do is vital in bridging gaps between the healthcare system and underserved populations in Missoula. Their services help people navigate housing in an increasingly expensive city and confront obstacles on their unique paths to health.
Source: Missoula CHW Program Evaluation, 2024
Community health workers themselves are impacted by Missoula's housing crisis, even as they work to support others. One community health worker recently decided to leave Missoula because they could not find stable, affordable housing. Addressing housing costs and availability in Missoula is critical to retaining all community members, including those tasked with helping to address the crisis.
I've moved every six months since I got here. . . A lot of it has been landlord turnover and rent raises and just ridiculous prices and getting priced out. . . But also it's a connecting point between me and my clients. . . I very much relate to anybody that's going through a housing crisis, just because I've moved so much.
How can we support community health workers at the local and state level?
The CHW workforce in Missoula and across the state is small, but growing. However, CHWs need support from their community and local government in order to ensure the sustainability of their positions and ability to continue helping our community members.
Local Funding and Connections
CHW positions in Missoula are currently reliant on a single, three-year CDC grant. Local organizations who benefit from CHW services could consider partnering to seek additional grants and other short-term funding options. The National Association of CHWs has also suggested several long-term funding options , such as healthcare organizations internally funding CHW positions in anticipation of return on investment from CHW-supported outcomes such as fewer missed patient appointments, increased medication and treatment adherence, and improved patient health outcomes. Future funding partnerships could help to develop current staff and organizational relationships, assure that CHWs are paid a living wage to improve retention, and expand CHW opportunities.
Coalition Building
Collaborative relationships with the Pov, MHA, and many other Missoula organizations have contributed to CHWs' successes in connecting community members to housing services. Addressing Missoula's housing crisis will take sustained engagement and coalition building across city and county agencies, community-based organizations, and community advocacy groups. CHWs are a vital part of any community-wide efforts to address homelessness and housing and should be included in these coalitions.
Statewide Policy & Definitions
Sustainable, long-term funding for CHWs can be supported on a state level in several ways, including through training and certification programs and state Medicaid policy initiatives that would involve embedding CHW services in core Medicaid operations. Statewide conversations about CHWs should involve CHWs themselves, as they are in the best position to understand the impact of potential funding options on their work. A uniform, statewide definition of CHWs would also help differentiate these roles from other patient support positions (e.g., patient navigators, patient advocates) and could include functionally similar roles such as Community Health Representatives, which are well established in the Indian Health Service.
