Medical and Emergency Medical Use by People Experiencing Homelessness before and after Placement in Supportive Housing James Petrovich, PhD, LMSW TCU Department of Social Work Kwynn Gonzalez-Pons, BS UNTHSC Department of Behavioral and Community Health Emily Spence-Almaguer, PhD, MSW UNTHSC Department of Behavioral and Community Health Subhash Aryal, PhD UNTHSC Department of Biostatistics and Epidemiology Joel Hunt, PA JPS Health Network Care Connections

Presenter Disclosure The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No Relationships to Disclose

This Study Assessed use of services in the 18 month periods before and after provision of supportive housing ED, Inpatient, outpatient clinic, urgent care, psych ED Examined service charges accrued before and after housing A component of the larger evaluation of Directions Home (directionshome.org) Provide a perspective on community-level impacts of supportive housing

Directions Home Fort Worth’s ten-year plan to make homelessness rare, short-term, and non-recurring Included housing, supportive services, outreach, employment training, and more Plan adopted in 2008 Programs initiated 2009 Funded at 2.9 million Largest program – permanent supportive housing 200 PSH units funded Justified based on the costs of reacting to homelessness

Research Questions Does the use of health care services change after placement in Directions Home supportive housing? If service use changes are observed, what are the accompanying fiscal costs / savings of these changes?

Methods Purposive sample of 100 individuals residing in Directions Home housing Out of 154 housed during PY I Completed demographics questionnaire Obtained homelessness-related information from local HMIS Obtained official health care records from John Peter Smith Health Network

Sample 100 individuals enrolled in the study 61 males / 39 females Mean age 51 years old Almost two-thirds (62%) African-American 3% Hispanic Mean homelessness 5.8 years Mean income $687 per month 65 (65%) reported no income

Sample 52% 26% 82% Percent reporting high school diploma, GED, some college 5 people reported military service Percent SSI or SSDI Percent reporting JPS as primary source of health care

Self-Reported Health Conditions Based on the Vulnerability Index

Self-Reported Behavioral Health Conditions 72% report a substance abuse problem 68% report receiving mental health treatment 54% report receiving substance abuse treatment 31% report injection drug use 18% report being committed for mental health care

Healthcare System Use Healthcare System Use

Healthcare Charges 40% Reduction M=$26, 456 M=$15, 907

Outliers $1,103,812 N=5 42% of all pre-housing charges $1,103,812 N=5 42% of all pre-housing charges $605,187 N=5 $38% of all post-housing charges 10% $435,458 N=1 Both Pre and Post Housing Pre-Housing Post-Housing

Healthcare Service charges – Outliers Removed

Summary: Service Use Service use changes after housing Service reductions observed for: ◦ ED use (60%) ◦ Inpatient admissions (53%) ◦ Psychiatric Ed (40%) ◦ Urgent care (30%) ◦ Overall JPS (24%) ◦ Outpatient clinic visits (7%)

Summary: Service Charges Total charges accrued post-housing decreased by $1,044,391(40%) Mean post-housing charges decreased by $10,549 (40%) With outliers removed, total charges decreased by $545,768 (36%) Mean post-housing charges decreased by $5,806 (36%)

Cost Offset? Cost of Directions Home Housing: ◦ Total = $397,500 ($3,975 x 100) ◦ Rent = $1,078,200 ($10,782 x 18) Total program cost = $1,475,700 Service charge reduction = $1,044,391 Net change = +431,309 Net Change= +431,309 (healthcare + housing + services)

Patients diagnosed with chronic conditions increased after housing +100% +53% +88% +26% +50%

Implications: Policy Services for people who are homeless are contested However, Homelessness stresses larger public service systems It is important to understand how interventions may impact these systems Study adds to existing knowledge base Informs local decision making around supportive housing

Implications: Practice Improved screening for chronic health conditions Identify and support “frequent-flyers” Improved, integrated health-care Facilitate linkage to primary / preventative care Support housing placement Support housing retention

Implications: Future Research Much more to be examined Preliminary examination of diagnostic data Outliers? Additional service use measurements (24, 36….) Predictors of service use?

Limitations Non-probability sampling approach (100/154) Participants scored high on VI so not considered representative of general homeless population Unable to control for extraneous variables impacting service use Charges typically inflated but true costs not available Only obtained data from JPS, other providers not included

Questions / Comments?