Health Homes for the Homeless: National and Local Opportunities

1. Health Homes for the Homeless: National and Local Opportunities Health Care for the Homeless TrainingHawaii Primary Care Association June 27, 2013 Brenda Goldstein, MPH bgoldstein@lifelongmedical.org

2. Life Expectancy

3. Nationally Hawaii • 12 – 15,000 annually • 6,000 on any given day • 23.5 – 39% are children • 17 – 42% are employed full time • 37% are Native Hawaiian

4. Special Populations

5. Increasing Elderly Homeless

6. HealthIssues • Homelessness • Advanced chronic disease – cancer/heart disease • Drug/alcohol addiction • Trauma • Serious mental illness • Poor nutritional status • Dental problems • Pregnancy/Youth • Low birth weight • Developmental delays • Emotional problems

7. Costs of Homelessness • Hospitalizations/re-hospitalizations • Average 4 days longer inpatient ($2,414) attributable to homelessness • Incarcerations • For mental health, drug and alcohol use related behaviors or simply for sleeping on the street or loitering • Emergency Services (ambulance, ER use) • Increased costs of unmanaged chronic disease

8. National Trends • Affordable Care Act: Expanded Coverage and Access • Medicaid Health Home Funding Opportunity for States • Triple Aim • Improve health and reduce mortality • Improve the experience for patients and quality of care • Control costs • Bending the Cost Curve • Reduce avoidable ED visits, hospital admissions/re-admissions • Avoid unnecessary nursing home stays • Focus on small number of consumers with highest cost • Patient Centered Health Homes Better health care for people experiencing homelessness is a strategy for achieving these goals

10. Health Homes for the Homeless • Model and payment to support intensive services • Flexible service models • Who provides care (non-licensed staff can be highly effective) • Where care is provided (office, home, streets) • What “care” is (medical, psychosocial, flexible funds) • Fast access to supportive housing and other housing resources • Linkages to benefits

12. Practical Approaches • Integrated team approach • High frequency of interaction: need determines intensity of services • Strong linkages to community-based services, especially housing • Low Caseloads • Non-licensed staff can be the most effective case managers • Close communication with partners (primary care, behavioral health, benefits advocates, ED, discharge planners)

13. Healthcare and Housing: Emerging Models • Housing First • Rapid re-housing • Health Centers and HCH programs obtain housing resources for homeless clients • Partnerships with non-profit housing providers/public housing authorities • Align resources for housing, health care, and behavioral health • Prioritize access to permanent housing • Chronic homelessness • Vulnerability Index • Frequent users of crisis services • Family reunification

14. What Is Supportive Housing? Permanent, affordable housing with combined supports for independent living • Each tenant may stay as long as rent is paid and compliance with terms of rental agreement • Affordable - tenant pays no more than 30-50% of household income • Access to support services, but participation is not required • Different housing options are available • Housing First models provide access for people with high risk behaviors and long histories of homelessness

15. Supportive Housing Cost-Effective Every Day

16. Supportive Housing: Making the Case • Reduces costly care • 29% fewer inpatient admits and 24% fewer ED visits in Chicago • 56% fewer ED visits and 44% fewer inpatient admits in San Francisco • 77% fewer inpatient admits and 60% fewer ambulance rides in Maine • Improves health outcomes • Access to primary care and engagement in recovery services • Medication adherence and enhanced motivation to change • Improved health indicators for HIV + patients • Reduced drug/alcohol use • Improved mental health status

17. Change is PossibleCA Frequent User 2 Year Results Medicaid Population *Indicates statistically significant

18. Health Center Opportunities • Creating homeless friendly health centers • Services in Supportive Housing • Respite care • Frequent ED user programs • Hospital discharge/care transition models • Veteran’s programs • Educate and enroll homeless in Medicaid

20. Collaboration • FQHCs - desirable partners • Healthcare: • linked to housing • embedded in mental health service sites • staff located in supportive housing • provided at shelters, transitional housing, board and care • Home visits • Mobile/street services

21. Financing Models • HUD grant opportunities • Managed Care Contracts • Hospital Contracts • FQHC billing for behavioral health services • Partnering with specialty mental health

22. Challenges for Clinics • High risk patients impact clinic productivity • Staff training to serve the population • Cultural differences when working collaboratively with housing providers • Clients need intensive, extended follow up – strain on resources

23. Policy Issues • Payments to primary care for intensive services and incentives for reducing overall cost • Managed care plans adopting appropriate care and reimbursement models • Case management as a recognized “medical” service • Eliminate barriers to qualify for SSI/Medicaid • Housing subsidies as cost effective health benefit • Discharge policies and funding for medical respite

24. Resources • National Health Care for the Homeless Council www.nhchc.org • SAMHSA-HRSA Center for Integrated Health Solutions http://www.integration.samhsa.gov • Opening Doors, Federal Strategic Plan to Prevent and End Homelessness www.usich.org • Corporation for Supportive Housing www.csh.org • Technical Assistance Collaborative www.tacinc.org • Contact: bgoldstein@lifelongmedical.org