Housing is Health Care Supportive Housing for People with Complex Health Problems

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Housing is Health CareSupportive Housing for
People with Complex Health Problems

• Carol Wilkins Director of Policy Research
  Corporation for Supportive HousingJune
  2009www.csh.org

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CSHs Mission
CSH helps communities create permanent housing
with services to prevent and end homelessness.
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Overview

• Overview of supportive housing approaches
  implemented by Health Care for the Homeless
  programs
• What have we learned about the relationships
  between homelessness and complex co-occurring
  health conditions?
• Lessons learned from supportive housing program
  initiatives for frequent users of crisis services
• Multiple vulnerabilities
• System failures high costs and poor outcomes
• Integrated care system and practice innovations
• Improved outcomes and reduced costs
• The impact of linking integrated care and
  supportive housing
• Policy implications short term and long term
  solutions
• FQHC reimbursement policy clarifications needed
• Coverage streamlining Medicaid eligibility
• Reimbursement policy reforms needed to support
  effective care coordination for poorest people
  with most complex health problems

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What Is Supportive Housing?A cost-effective
combination of permanent, affordable housing
with services that helps people live more stable,
productive lives.
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Defining Supportive Housing

• Permanent affordable housing with combined
  supports for independent living
• Housing is permanent, meaning each tenant may
  stay as long as he or she pays rent and complies
  with terms of lease or rental agreement
• Housing is affordable, meaning each tenant pays
  no more than 30 to 50 of household income
• Tenants have access to an array of support
  services that are intended to support housing
  stability, recovery and resiliency, but
  participation in support services is not a
  requirement for tenancy
• Options available for adults who are single,
  those who choose to share housing, and families
  with children
• Housing First low demand models provide
  access for tenants with long histories of
  homelessness and significant obstacles to housing
  stability

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HCH and Supportive HousingA range of approaches
and choices responding to a range of
opportunities and program capacity

• HCH as supportive housing project sponsor or as
  service partner with experienced housing
  developer
• Partnerships and ongoing communication between
  service providers and property managers are
  essential
• Single site or scattered site housing models
• HCH provides services linked to tenant-based rent
  subsidies (e.g. Shelter Plus Care)
• Home visits and mobile services, on-site clinics,
  or linkages to off-site clinic and other services
• Licensed clinical staffing, paraprofessionals,
  peers, and multi-disciplinary teams

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The connection between homelessness and complex
health conditionsMaking the case for
investments in supportive housing

• Medicaid and health systems incur substantial
  costs providing care to homeless people often
  without achieving good outcomes
• Costs of serving homeless people with serious
  mental illness up to 40,000 / year or more
  mostly in health care systems
• 28,000 annual costs in Maine mostly health care
  in hospitals
• 28,000 average annual health costs for Boston
  street dwellers
• Health care costs for public inebriates exceed
  8,000/year
• 46,700 average Medicaid charges prior to move-in
  for homeless chronic alcoholics in Seattle (1811
  Eastlake)
• Homeless people with complex, co-occurring
  health, mental health and/or substance use
  disorders are most frequent users of emergency
  room care
• 45 of participants enrolled in CA programs for
  frequent users of ED were homeless (up to 60 in
  urban projects)

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Frequent Users of Health Services

• Californias Frequent Users of Health Care
  Services focused on a small group of individuals
  who frequently use emergency departments
  (www.frequenthealthusers.org)
• Repeated and avoidable emergency room visits
  Average 8.9 ED visits and 5.8 inpatient days
• Similar profiles of frequent users of other
  systems detox / sobering centers, psychiatric
  emergency and inpatient care, jails and shelters
• Complex, unmet needs not effectively addressed in
  high cost acute care settings
• Chronic illness, substance use, mental illness,
  homelessness
• Barriers in accessing medical care, housing,
  mental health care, and substance abuse treatment
• Extreme poverty, social isolation, victimization,
  lack of family support, minority race, stigma

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Who Are Frequent Users?Frequent Users of Health
Services Initiative (CA)

• 65 chronic illness (diabetes, cardiovascular
  disease, chronic pain, cirrhosis other liver
  disease, asthma other respiratory disease,
  seizures, Hepatitis C, and HIV)
• 53 substance use issues (alcohol,
  methamphetamines, crack/cocaine, heroin,
  prescription drugs)
• 45 homeless, living on the streets
• 32 mental illness (Axis I and II)
• 36 have 3 of these presenting conditions

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Chronic Homelessness Chronic Disabling
Health ProblemsPotentially Medicaid eligible
but often not enrolled (yet)

• High rates of mental health substance abuse
  disorders
• Chronic health problems increasingly significant
• Heart disease, hypertension, diabetes, emphysema,
  liver disease, asthma
• Hospitalization for medical condition more likely
  than mental health hospitalization
• High mortality rates
• Aging average age of single adults in shelters
  and supportive housing for chronically homeless
  is near 50
• Heavy users of shelters (gt6 months/year) more
  likely to be African American and over age 50
• Majority not receiving SSI or Medicaid benefits
  (yet)
• 35 with any subsidized health insurance in HUD
  study of programs for chronic homeless with
  serious mental illness
• 36 with Medicaid in Chicago study of homeless
  patients with inpatient hospitalization for
  chronic medical conditions
• In most troubled homeless families, out-of-home
  placement for child may lead to lost Medicaid
  benefits for parent with behavioral health
  problems

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System and Practice Innovations

• Data analysis to identify high-cost frequent
  users
• Data matching / integration to identify frequent
  users of hospitals and/or multiple systems
• Data systems flag frequent users and connect to
  more appropriate care
• Vulnerability assessments to identify those with
  greatest risk of mortality or avoidable
  hospitalizations
• Linkages between hospital or jail and community
  providers to support inreach and care
  coordination
• Medical respite care to reduce hospital stays
  re-admissions
• Permanent supportive housing as foundation for
  recovery
• Integrated services by multidisciplinary teams
  and case conferencing for medical, mental health,
  and substance use problems
• Chronic care management instead of episodic acute
  care
• Ongoing partnerships among agencies and direct
  service providers with shared goals for shared
  consumers

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Components of Effective Service Strategies

• Outreach and assertive and patient engagement to
  overcome barriers resulting from isolation and
  symptoms of mental illness or addiction
• Integrated care for medical, mental health, and
  substance use problems
• Trauma informed services
• Establishing trust
• Restoring hope
• Harm reduction
• Enhancing motivation to change harmful / risky
  behaviors
• Practical support to meet basic needs and respond
  to individual preferences and goals
• Helping people get and keep housing

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Impact Of Supportive Housing

• Supportive housing significantly reduces the need
  for costly emergency care and hospitalizations
• 45 fewer days of nursing home care in
  preliminary results from Chicago Housing Health
  Partnership (CHHP) study
• 29 fewer inpatient hospitalizations and 24
  fewer emergency room visits in Chicago (compared
  to usual care)
• 56 fewer emergency room visits and 44 fewer
  inpatient admissions in San Francisco
• 77 fewer inpatient hospitalizations and 60
  fewer ambulance transports in Maine
• 34 fewer emergency room visits and 40 fewer
  inpatient hospital days in Denver
• Health outcomes improve with better engagement in
  more appropriate outpatient care
• Access to primary care and engagement in recovery
  support services
• Medication adherence and enhanced motivation to
  change

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Improved Outcomes Reduced Costs

• Seattle DESC 1811 Eastlake project for homeless
  people with chronic alcohol addiction
• 41 reduction medical expenses
• 87 reduction sobering center use
• 45 reduction county jail bookings
• NYC FUSE Initiative for frequent users jail
  shelter
• Reduced jail days 52 for housed participants
• Jail days increased for comparison group

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Outcomes Hospital Utilization Charges
Frequent Users of Health Services Initiative (CA)

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Supportive Housing Increases Impact Of
Multidisciplinary Care

• Homeless frequent users receiving services AND
  connected to permanent housing
• Reduced average ED visits 34
• Reduced average inpatient days 27
• Reduced average inpatient charges 27
• Homeless frequent users receiving services but
  NOT connected to permanent housing
• Reduced average ED visits 12
• Increased average inpatient days 26
• Increased average inpatient charges 49

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Housing is Health Care

• Chicago Housing Health Partnership Study
• In this randomized trial, we found that housing
  hospitalized homeless HIV-positive individuals
  and providing them with intensive case management
  can increase the proportion surviving with intact
  immunity and decrease overall viral loads. The
  63 relative increase and 21 absolute increase
  in survival with intact immunity is clinically
  meaningful. For every 5 patients offered this
  intervention and for every 3.25 patients provided
  housing in a program agency, 1 additional patient
  will be alive with intact immunity.
• Buchanan, Kee, Sadowski Garcia
• American Journal of Public Health June 2009

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Paying for What Makes SenseImplications
ChallengesFinancing Multidisciplinary Care
the big picture

• Costs and savings are often in different systems
  of care
• Carve-outs can create disincentives if behavioral
  health services costs increase while biggest
  savings are in medical costs.
• Coordinated investments are needed for housing
  and services.
• Medicaid match and other costs and savings may be
  at different levels of government (state vs.
  county)
• Opportunities to maximize savings may be greatest
  when focusing on chronic homelessness and/or
  homeless frequent users of emergency and
  inpatient services
• BUT for some of the most vulnerable people with
  serious health conditions, increased utilization
  of health services may be appropriate

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Opportunities Challengesfor HCH Community
Health CentersShort term

• Federal policy clarification needed for FQHC
  reimbursement for costs associated with
  multi-disciplinary teams
• Include case managers and other team members in
  FQHC rate calculation as allowable costs
• HRSA should provide targeted federal grant
  funding for innovative and effective models of
  comprehensive care for the poorest patients with
  most complex health problems and frequent users
  of crisis care
• States need to clarify guidance for reimbursement
  for FQHC providers who deliver services covered
  as optional benefits
• Facilitate integration of FQHC core services by
  clinicians with rehabilitation or targeted case
  management services
• Facilitate access to Medicaid benefits (SOAR)

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Opportunities Challengesfor HCH Community
Health CentersComprehensive Reform is Needed

• Streamline Medicaid eligibility based on income
  instead of complex categorical eligibility
• Cover everyone below federal poverty level (at
  least!)
• Modify payment systems to finance integrated
  services by multidisciplinary teams for people
  with complex medical and behavioral health
  problems
• Use Medicaid waiver authority or establish new
  demonstration program to encourage states and
  providers to collaborate to improve care and
  control costs
• Implement and document innovative care management
  and person-centered health care home models
  implemented by Health Centers, HCH programs
  other community providers

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For more information visit www.csh.org

• See the report prepared by National Health Care
  for the Homeless Council and CSH available at
  http//documents.csh.org/documents/pubs/CSHNHCHCHe
  althCentersReportNov07.pdf