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Montefiore in the News

January 17, 2020

Risk Staff

Connecting Patients to Housing and Improving Health Outcomes

By Keona Serrano, Project Manager, Montefiore Housing at Risk Program

HEALTH- When people face housing insecurity, their health often takes a back seat. Research shows that housing insecurity is one of the top barriers to improved health outcomes. People facing eviction, living on the streets, living in shelters, living in overcrowded apartments with family, couch surfing, or renting are all at risk for poor health.

Since 2009, Montefiore Health System’s Housing at Risk Program has been working to improve the situation by providing coordinated health and housing support to patients in the Bronx. The Housing at Risk team — Director Deirdre Sekulic, Project Manager Keona Serrano and Social Worker Madeline Gotay — help Montefiore patients with their housing dilemmas, with the goal of reducing avoidable Emergency Department visits and hospital stays.

Many patients are referred by social workers, but Montefiore has also created an automated alert system to identify patients in the Emergency Department who may be in housing situations that effects their health, enabling the team to proactively reach out and offer support.

The team works hand-in-hand with nurses, physicians and other health care providers to make appointments, schedule medical transportation and follow up about care plans. This is all in an effort to give patients access to preventative care and to pull them out of the cycle of waiting until their health deteriorates and they need emergency care. The team also has strong connections to a variety of Bronx community-based organizations to support patients with unstable housing.

Since the program was created, the Montefiore Housing at Risk team has addressed the needs of hundreds of patients. They have successfully gained stable housing through intensive interventions such as assessments, phone calls, visits and accompanying patients to other agencies to receive benefits.

As 2020 begins, the Housing at Risk Program will continue its dedication to this important program, looking for even more ways to address housing issues that may prevent Montefiore patients from improving their health and overall quality of life.

For more information about the Montefiore Housing at Risk Program, please contact Keona Serrano at