Housing As Health Care NPH Conference Sharon Rapport, CSH October 3, 2014

Our Mission Advancing housing solutions that: Improve lives of vulnerable people Maximize public resources Build strong, healthy communities At CSH, it is our mission to advance housing solutions that deliver three powerful outcomes: improved lives for the most vulnerable people maximized public resources strong, healthy communities across the country. CSH is working to solve some of the most complex and costly social problems our country faces--like those related to homelessness. We envision a future in which high-quality supportive housing solutions are integrated into the way every community serves the men, women and children in most need.

A Blueprint for Scaled Replication An Innovative & Effective Model CSH Social Innovation Fund GOAL: National replication of integrated supportive housing and health services model as a viable alternative to the “revolving door” for homeless people who are frequent users of crisis health care services FUNDING: $1.15 M annual award from Corporation for National and Community Service (CNCS): 5 yrs $425,000 annual award to Tenderloin Neighborhood Development Corporation $375,000 annual award to Economic Roundtable A Solid Base of Evidence A rigorous evaluation on supportive housing‘s effectiveness as a health care intervention for reaching Medicaid‘s high-need, high-cost individuals A Blueprint for Scaled Replication Develop a viable policy for Medicaid-funded intensive care management services are paired with federal, state, & local housing resources z An Innovative & Effective Model Develop and refine a model of housing linked to care management and coordinated primary and behavioral care through community partnerships. STRATEGIES: SITES: San Francisco, CA Los Angeles, CA Hartford, CT Ann Arbor, MI Tenderloin Neighborhood Development Corp. The Economic Roundtable Connecticut AIDS Resource Corporation Catholic Social Services of Washtenaw County

Kelly Cullen Community in San Francisco: Key Partners TNDC SUPPORT SERVICES TNDC PROPERTY MANAGEMENT SAN FRANCISCO DEPT OF PUBLIC HEALTH LUTHERAN SOCIAL SERVICES TENANT SERVICE INTEGRATION

10th-Decile Model in Los Angeles 10th Decile triage tool highest-cost, highest-need 10% of homeless individuals Collaboration hospitals, FQHCs, homeless services Health Homes intensive case management/ care coordination Permanent Supportive Housing housing navigation and retention Primary care Behavioral health Substance abuse Supportive Housing Navigator Frequent Users The Glue: Intensive Case Management i.e., Care Coordination + Housing Navigation The FUSE program model has 4 components: 10th decile triage tool Collaboration between hospitals and community-based providers Intensive case management by experienced homeless services providers Permanent supportive housing The first component, the triage tool, was developed by the Economic Roundtable All of our frequent user programs utilize the research of the Economic Roundtable to identify the 10% highest-cost, highest-need chronically homeless patients. What is the triage tool? short series of questions that can be administered in 20 minutes to homeless individuals in hospitals by a medical professional or social worker then run against an algorithm to quickly and accurately predict whether or not a homeless patient fits into the top 10% of hospital users The triage tool allows hospitals to quickly recognize which patients are most costly and most in need of supportive housing The second component is collaboration between hospitals, homeless services providers, FQHCs, mental health providers, substance abuse treatment providers, and supportive housing providers. These collaborations help to ensure our participants, who all have chronic health conditions, receive integrated care coordination through services supporting whole person care. The third component is intensive case management and housing navigation. Homeless services providers experienced in working with the chronically homeless ensure that participants get the care and housing they need. FUSE homeless services providers: Verify that patients are in 10th decile Ensure benefits enrollments and temporary housing placements Connect frequent users to FQHC and mental health services Submit permanent housing applications, find apartments, help clients move in, Continue supportive services after clients move into permanent housing FQHC partners provide initial and follow up health services and a medical home The fourth component— is permanent supportive housing—defined as Affordable housing where supportive services providers engage tenants in voluntary health & social services (such as mental health and addiction therapy, medical care, and case management) Supportive housing comes with HUD rental subsidies through local housing authorities. These subsidies make housing affordable, and tenants pay 30% of their income towards rent. As you may know, the federal sequester has impacted our program. It is now much more difficult to access housing vouchers for supportive housing rental subidies. 19-Nov-18

10th Decile Hospital Utilization and Cost Avoidance (Actuals): 81% Average Decrease In Total Costs Per Client Per Year ER utilization down 71% Hospital readmissions down 85% Inpatient days down 81% ER costs down 66% Inpatient costs down 83% Total costs decreased 81% 2013 data for the 60 clients shows that ER utilization went down 71% from 9.8 to 2.8 visits per year Hospital readmissions decreased 85% from 8.5 to 1.2 admissions per year Inpatient days were down 81% from 28.6 to 5.5 inpatient days per year The impact on hospital cost avoidance was significant for these 60: total ER costs were down 66% for these patients from $7,500 to $2,500 total inpatient costs were down 83% $65,000 to $11,400 Housing these 60 individuals have resulted in $5.7 M in hospital cost avoidance! The average cost avoidance was $60,000 per person Largest individual cost avoidance : $2.2 million 25% of the cohort avoided costs in excess of $100,000 Average cost avoidance per person: $59,415 Largest individual cost avoidance: $2.2 million 25% of the cohort avoided costs in excess of $100,000 Source: FUSE/SIF hospital cost data, September 2013 19-Nov-18

AB 361. “Health Homes” Bill (Mitchell) Health Home = Virtual “Home” for Addressing the “Whole Needs” of a Beneficiary Uses an option under Affordable Care Act to create a “Medi-Cal health home benefit” to Medi-Cal beneficiaries who are— FREQUENT HOSPITAL USERS and CHRONICALLY HOMELESS PEOPLE Bill signed by Governor Oct 2013 Frequent Hospital User Beneficiaries Chronically Homeless Beneficiaries By tapping into an ACA option, we believe AB 361 creates an opportunity to offer the services that supportive housing has been providing to vulnerable populations for years. AB 361 would allow the state to apply for a Health Home State Plan Amendment. If the state applies for the option, it would be required to create a Medi-Cal benefit that would offer “health home services” to Medi-Cal beneficiaries who are frequent hospital users and to beneficiaries who are chronically homeless.

Health Home Services Services to Address the Needs of the “Whole-Person” COMPREHENSIVE CARE MANAGEMENT CARE COORDINATION & HEALTH PROMOTION COMPREHENSIVE TRANSITIONAL CARE INDIVIDUAL AND FAMILY SUPPORTS REFERRAL TO COMMUNITY & SOCIAL SERVICES HEALTH IT, DATA AND EVALUATION The services this new benefit would fund include— Comprehensive Care Management Care coordination and health promotion Comprehensive transitional care Individual and family supports Referral to community and social services Health IT, data and evaluation The ACA doesn’t mention outreach and engagement of populations health homes target, but federal guidance indicates outreach and engagement are critical services that make all of the listed services possible, so the benefit would also offer outreach and engagement. Health homes cannot pay for housing, but the benefit can pay for the services to link someone to housing and help them stay stable OUTREACH & ENGAGEMENT

Define Services: Frequent face-to-face contact (1:20 ratio) Implementation of AB 361 Define Services: Frequent face-to-face contact (1:20 ratio) Comprehensive care management: Outreach/engagement Motivational interviewing to identify all needs (not just health) & plan to meet all health-impacted needs Assist beneficiary get into housing Promote housing stability: help beneficiaries learn to manage finances, pay rent, shop for or gain access to healthy food, maintain eligibility for benefits, communicate with neighbors & management, and participate in community Care coordination & health promotion: Include HH staff advocacy with health providers Referral to social services & supports: Include partnerships with permanent housing

Next Steps on Health Homes Webinar: Oct-Nov Stakeholder Process Draft State Plan Amendment Concept Paper Implement (mid-2016) Ongoing Stakeholder Meetings Advocacy w/DHCS

Sharon.Rapport@csh.org (323) 243-7424 (c) (213) 623-4342, x18 (o) \