Integrating Behavioral Health Services and Housing

1. Integrating Behavioral Health Services and Housing Marcus Cannon, LMFT Behavioral Health Services Supervisor, HHOPE Program Riverside University Health System – Behavioral Health • February, 2019

2. FUNDAMENTALS“Wellness Begins with a Home” 2

3. Riverside University Health System Consolidation of County departments RUHS – Medical Center RUHS – Public Health RUHS – Community Health Centers (11 primary care clinics countywide) RUHS – Behavioral Health (mental health & substance abuse prevention & treatment) Homeless Housing Opportunities Partnership & Education (HHOPE) Program – responsible for housing and homeless services department-wide Riverside County is 7,208 square miles; approximately same land area as New Jersey. 3

4. Why social determinants? Average life span of RUHS-BH consumer is 42 years! The solution to homelessness is housing. Behavioral health treatment (in some form) is often needed to get and keep housing. “A rose by any other name would smell as sweet.” Target population 4

5. Invest in people and process Staff are our greatest asset in this work Process: It works if you work it! Grease the skids! Structure the environment to make client success as easy as possible. 5

6. Housing First is a beginning not an ending Prioritizing recovery (etiology is slippery) Use client goals to drive treatments and social supports/determinants needed to achieve goals Integrated services In-house Partnerships 6

7. BH Interventions & HomelessnessQ: Is it the chicken or the egg? A: Yes. Motivational Interviewing (MI) Rolling with resistance Trauma informed care Wellness Recovery Action Plan (WRAP) Recovery Management (RM) Dialectical Behavior Therapy (DBT) Peer Support Specialists Staff with lived experience of mental health and substance use services, recovery, and training in using personal recovery to facilitate recovery in others Securing housing prior to entering residential treatment Long-acting injectable medications 7

8. What is a Recovery Environment? 8

9. Outcomes Martha T.: working with the voices to teach distress tolerance skills CVPH super utilizers JR: 123 admits in five years, entered PSH 18 months ago – 0 admits! JJ: 46 admits in six years, entered PSH 18 months ago – 1 admit! JM: 117 admits in six years, entered PSH 8 months ago – 0 admits! “Ventilating” room: reframing 90%+ retention rates in RUHS-BH PSH 9

10. INITIATIVES 10

11. Housing Crisis Response Teams Mobile response to homeless individuals and encampments with behavioral health specialist and peer support specialist Client driven goals Housing and healthcare focused Focused on rapport – cold water Diverse team (most have been homeless themselves, racially diverse, mixed genders, LGBT) Using MI, TI, CBT, DBT skills 11

12. Community Service Center teams Teams of mobile staff (behavioral health specialist, peer support specialist, and community service assistant) to support life skills development (not FSP clinic case managers) Serving chronically homeless residents in their homes Vital link between activities of daily living and formal behavioral health services Integral to treatment engagement and housing retention By being recovery focused and life skills focused these teams help residents focus on improved functioning—this leads to a natural segue into treatment to support this functioning Not focused on etiology or diagnosis Leads to improved treatment engagement Not constrained by same logistical demands of clinic staff (e.g. productivity, treatment fidelity, scheduling) 12

13. Housing Resource Specialists Behavioral health specialists focused on integrating behavioral health with housing Support landlords with tenant concerns 24/7 Support RUHS-BH clinics with housing resource linkage Bridge landlord and clinical relationships through mediation and problem solving meetings 13

14. Coachella Valley Permanent Housing and Riverside Permanent Housing Extremely low demand project-based permanent, supportive housing (25 units each) Shared kitchen and living spaces In vivo life skills development Onsite peer support staff 24/7 Co-located RUHS-BH FSP clinic 14

15. Mobile Psychiatric Services Psychiatrist, nurse, behavioral health specialist, and peer support specialist as a mobile team You’ve heard of doc-in-a-box—this is doc-in-a-van! Data driven targeting top 40 adult utilizers of psychiatric services in Western region Close partnership with HHOPE (RUHS-BH housing services) 15

16. Jail High Utilizers Countywide Top 25: #1 had 97 arrests last year Booking cost is ~$1500 and arrest with court is ~$27,000 97 arrests x $27000 = $2.6 million for one consumer All crimes of homelessness, substance use, and mental health: drunk in public, disorderly conduct, trespassing, vandalism, etc. In one year over 15 of the 25 housed Use data to make your case to finance upstream services 16

17. Full Service Partnership clinics Clinic model for highest need consumers with a prioritization for homelessness Multidisciplinary team that includes a psychiatrist, a nurse, a team lead, a clinical supervisor, wellness partners with experience in drug, alcohol and mental health treatment, and specialists in housing, education and employment Services include, but are not limited to: Outreach and engagement Comprehensive assessment and treatment Community-based wraparound services Intensive case management Money management / representative payee 24/7 availability Housing support Medication support and education Vocational and educational services Benefits establishment 17

18. Coordinated Entry System Riverside County CoC is unique in having RUHS-BH as the CES Lead Agency Coordination of BH services and trauma informed care Get your BH services involved in CES Cross pollination: non-profit community and County BH services can challenge and support one another Facilitation of disability verifications via mobile BH resources 18

19. Mainstream Housing Choice Vouchers (Section 8) Partnership Housing Authority, County of Riverside set aside Mainstream HCV for homeless and at-risk of homelessness exiting institutions Fills a gap left by HUD CoC Chronic Homeless definition RUHS-BH supporting initial outreach, housing acquisition, and ongoing case management via a mobile clinical therapist, behavioral health specialist, and peer support specialist 19

20. AB-109 Housing Riverside County Probation has allocated money for emergency and transitional housing for homeless probationers upon release RUHS-BH provides behavioral health case managers to conduct home visits and work toward self-sufficiency plans with probationers Staff are focused again on daily living but this often leads into clinical screening and treatment goals Provide bus passes, hygiene kits, food to newly released probationers Assist with case management activities in the community to provide immediate value to the probationer—leads to relationships that facilitate bh treatment 20

21. Whole Person Care A State Funded Program (With matching MHSA funding) designed to identify newly released Probationer needs and provide linkages to services In Riverside County our Whole Person Care pilot was created and is led by Judi Nightingale, DrPH, RN, Director of Population Health for Riverside University Health System Whole Person Care slides generously provided by Judi Nightingale 21

22. WPC Pilot Objectives Upstream identification of Behavioral and Physical health, substance abuse, housing and social service needs and linkages to services Coordination of care - right place/right time Decrease expensive and unneeded ED visits, hospital usage, reduce criminal behavior and jail recidivism Increase access to housing and existing community support systems/services 22

23. Data on costs of care $1,233 – average emergency room visit $12,000 – average hospitalization $34,000/year – average cost of homelessness per person $50,000/year – average cost to house one inmate in jail Without early identification and adequate referrals and support, former inmates suffering from mental illness and/or physical ailments are substantial contributors to these costs. 23

24. Probationer Data On average, 350-450 probationers are homeless at any single moment, about 3% of the county’s supervised population. About half of all probationers in the county return to court within the first year as a result of substance abuse. 24

25. 2015 Probationer Data (cont.) As many as 50% of probationers need medical insurance. Many qualify for Medi-Cal, but have not enrolled. According to national statistics, a large number of returning prisoners have HIV/AIDS, hepatitis B, and tuberculosis. Many probationers have co-morbid Behavioral and Physical health conditions (esp cardiac). Reduction in life span is est. at 20 years. 25

26. WPC Screening since 10/6/2017 26

27. WPC Referrals 27

28. Contact mcannon@ruhealth.org Marcus Cannon, (951) 715 – 5050 http://www.ruhealth.org/en-us/behavioral-health 28

29. Riverside University Health System – Behavioral Health Integrating Behavioral Health Services and Housing