Promising Models for Tenancy Support to Improve Housing Stability

1. Increasing Housing Stability: Assessing Promising Tenancy Support Models to Inform Local, State, and National Policy and Practice Donna Biederman, Emily Carmody, Mina Silberberg

2. Increasing Housing Stability: Assessing Promising Tenancy Support Models to Inform Local, State, and National Policy and Practice

3. Housing matters… Homelessness is a risk factor for poor health:1-4 Research shows that Permanent Supportive Housing is associated with less homelessness and improved health. 5-12 Medicaid funding can increase supply of PSH More research needed on TSS services Risk associated with poor implementation

4. Study goal Study promising practices in tenancy support services (TSS) to provide information to North Carolina Department of Health and Human Services (NC DHHS) for Medicaid funding.

5. Key stakeholders NC DHHS Louisiana Department of Health (LA DOH) and LA Housing Corporation Consumer Advisory Council (CAC) NC Agencies: Homeward Bound, UNC Center for Excellence in Community Mental Health

6. Our research questions • What constitutes effectiveness of supportive housing? Is improved health one of those outcomes? • What are the practices of effective TSS providers? • Which aspects of provider agency context support effective TSS that is responsive to client needs and accessible to a diverse population? Which create challenges? • Which aspects of local, state, and federal regulation support delivery of effective TSS that is responsive to client needs and accessible to a diverse population? Which create challenges? What are the benefits and challenges for providers to use Medicaid funding for TSS?

7. Methods

8. Our study design

9. Data sources Conducted interviews and focus groups with key sources in NC and LA (90 participants): • Homeward Bound • UNC Center for Excellence • NC DHHS leaders • LME/MCO housing specialists • LA state leaders • LA agency leaders Quantitative data (Clients with activity from 10/01/13 - 9/30/17): • NC HMIS • UNC Center for Excellence program data

10. Results: Who is PSH serving?

11. Relationship to head of household (n=7995)* *466 missing

12. Key client characteristics for heads of household > 18

13. Disabilities (n=5115)

14. Number of episodes of homelessness in past 3 years (n=3408)

15. Number of months experiencing homelessness in past three years (n=2988)

16. Program length of stay in days for first episode (n=2708)

18. Housing at program discharge (n=2468)

19. Results: What are the outcomes of effective TSS?

20. Prevalent outcomes of PSH cited across respondents “It’s just something you would have to experience, to see the glow on their faces. …You see the light come on in their life, you know, by just having housing -- stable housing.” Increased housing and housing retention Improved health Social connections Overall quality of life

21. Income and benefits at entry to and exit from services*  *If not yet exited, % at latest recorded point. **Change from entry to exit is statistically significant using McNemar's Test and p<.05;.05/14 (.0036) = Bonferroni-corrected alpha level.

22. TSS can have enormous benefits, and…. Finding stable housing might require instances of rehousing. It takes some people years to become invested in having a home. Some people require on-site supportive housing like RHD and Woodfin.  Being housed can mean the loss of former social connections.  Some people become sicker when housed, e.g., by not eating well. The health-housing relationship can be bi-directional. Can be difficult to balance different housing needs. ...realizing its full potential can require ongoing services.

23. What are promising practices for service delivery?

24. Agencies identified shared promising practices for providing effective tenancy support services. Housing First Staff training Individualized, flexible services Creative problem-solving within formal protocols Specialized positions and teams

25. The biggest challenge for TSS providers is locating affordable, safe, decent, and accessible housing

26. TSS increases landlord and developer willingness to provide access to units. Effective TSS Access to Housing

27. What are key factors to consider in the policy/regulatory environment?

28. Louisiana has seen benefits from using Medicaid funding for TSS… • Increase in independence • Reduced hospitalizations • Reduced institutional care • Improved health outcomes • Reduced Medicaid expenditures …. and NC respondents are excited about this too.

29. Creating an effective service definition requires balance.

30. Balance requires infrastructure to support implementation. EFFECTIVE TSS Braided Funding Training and TA at all Levels QA at all Levels Collaboration Across Agencies STATE INFRASTRUCTURE

31. Impact

32. Research symposium held in April. Collaborative learning  Relationship building  Policy impact  New project ideas

33. Implementation of CST for tenancy supports changed. LME/MCO technical assistance Quality review checklist to evaluate providers Intensive provider training New quality assurance process Request for evaluation

34. Informed Healthy Opportunities service definitions and rate settings. Participated on North Carolina Healthy Opportunities Fee Schedule Advisory Panel Research assisted in identifying services and payment strategy

35. References 1. Shalen E. Homelessness is an independent risk factor for cardiovascular disease hospital readmission in the California Health Care Utilization Project.  Circulation. 2017;135(suppl_1):AP333. 2. Castellow J, Kloom B, Townley G. Previous homelessness as a risk factor for recovery from serious mental illnesses. Community Ment Health J. 2015; 51(6):674-84. 3. Oppenheimer S, Nurius P, Green S. Homelessness history impacts on health outcomes and economic and risk behavior intermediaries: new insights from population data. Fam Soc. 2016;97(3):230-42. 4. Morrison D. Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. Int J Epidemiol.2009;38(3):877-83. 5. Burt MR. Impact of housing and work supports on outcomes for chronically homeless adults with mental illness: LA's HOPE. Psychiatr Serv, 2012;63(3):209-15. 6. Byrne T, Fargo JD, Montgomery AE, Munley E, Culhane DP. The relationship between community investment in permanent supportive housing and chronic homelessness. Soc Serv Rev.2014;88(2):234-63. 7. Rog DJ, Marshall T, Dougherty RH, et al. Permanent supportive housing: assessing the evidence. Psychiatr Serv. 2014;65(3):287-94. 8. Benston EA. Housing programs for homeless individuals with mental illness: effects on housing and mental health outcomes. Psychiatr Serv, 2015;66(8):806-16. 9. Henwood BF, Katz ML, Gilmer TP. Aging in place within permanent supportive housing. Int J Geriatr Psychiatry. 2015;30(1):80-7. 10. Collins SE, Malone DK, Clifasefi SL, et al. Project-based Housing First for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories. Am J Public Health. 2012;102(3):511-9. 11. Buchanan D, Kee R, Sadowski LS, Garcia D. The health impact of supportive housing for HIV-positive homeless patients: a randomized controlled trial. Am J Public Health. 2009:99(Suppl_3):S675-80. 12. National Academies of Sciences, Engineering, and Medicine. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: The National Academies Press; 2018.