Presentation to the Greater Columbia ACH Housing Summit March 19, 2019 D. Patrick Jones, Ph.D.

1. Review of Homelessness in the Tri Cities & of the Literature on Effects of Permanent Supported Housing Presentation to the Greater Columbia ACH Housing Summit March 19, 2019 D. Patrick Jones, Ph.D. Institute for Public Policy & Economy Analysis

2. My assignment—2-fold  • Provide a quick sketch of the status of the homeless in Benton & Franklin Counties • Review of the national experience in housing a segment of the homeless population • Population:  Chronically homeless • Response:  Permanent Supported Housing (PSH) • Besides a summary of the literature’s findings, will present a recent case study from Los Angeles

3. Homelessness in Benton-Franklin Counties – what do we know? • Point in time (PIT) count – Benton Franklin Trends • Other counts & sources – Kidder Mathews, courtesy of Catholic Charities of Spokane • “Snapshot” of Homelessness (also a January count)– from WA Dept. of Commerce, supplementing the PIT • Homelessness Management Information System (HMIS) – an annual count based on continuous case management • Not going to consider student homelessness (McKinney-Vento definition)

4. Definition of Chronically Homeless • Either:  1) someone who has been continuously homeless for a year, or 2) one who has experienced four episodes of homelessness in the past three years • Relative size of chronically homeless of total homeless population in the two counties (PIT estimate)? • 2018: 26% • 2014-2018 average: 15%

5. Who are they? Key characteristics of King County’s chronically homeless(from 2018 PIT count, courtesy of Kidder Mathews) Male 97% With children 3% Unsheltered 71% Psychiatric/emotional conditions 63% Substance abuse 63%

6. A proxy measure of chronically homeless from "Snapshot of Homelessness" (WA Commerce) • Augments the PIT count; is a "January number," too • 2 large categories:  "unstably housed" & “literally homeless" (emergency sheltered or unsheltered) • January 2017 estimate for Benton & Franklin • Literally homeless:  845 (~25% of "Snapshot" total) • Note:  don't know how many fit the definition of chronically homeless

7. Another proxy measure of the chronically homeless from the HMIS (WA Commerce Dept.) • Living situation of BF counties’ homeless householdsbefore entering the HMIS for FY2017-18 • Sheltered:  134 • Unsheltered: 248 • Total homeless households of 982 • How many of the homeless (people) have already found PSH? 61 out of 2,085, or 3%

8. Kidder Mathews Conclusion “The conservative PIT count & anecdotal evidence from local service providers suggest a chronically homeless population of at least 30 individuals in a given year.” “Assuming a 50-unit prototype project described in this report… it is my opinion that baseline homeless demand…with a preference/priority for the chronically homeless is deep enough to support development.”

9. Sources used for the review of the U.S. experience in PSH:  National Academy & Rand

10. Some detail from the National Academy review • Committee consisted of 11, mostly academics, headed by Kenneth Kitzer, M.D. Ph.D., U-C Davis Institute for Population Health Improvement • Over 300 studies reviewed • Besides a comprehensive review, committee was also asked to provide recommendations to provide better research. • Completed in 2018

11. Some detail from the Rand study (2017) Geography:  Los Angeles County Measures:  changes in outcomes of the chronically homeless, over a 24 month period Timeframe: 2010-2016 N = 890 Utilized data from the County’s integrated data system

12. Let's define PSH • An intervention with two components: 1) non-time-limited housing, and 2) an array of voluntary, supportive services • Typical services • Client outreach & engagement • Ongoing case management • Medical home, covering mental, SUD & physical health • Assistance with life skills • Employment preparation

13. Questions to investigate • Does PSH keep homeless stably housed? • Does PSH reduce costs of treating these homeless? • Are the savings from avoided expenditures by healthcare providers & government large enough to offset PSH costs? • Do those in PSH enjoy better health outcomes than homeless without PSH?

14. Methods used by studies reviewed – ranked by rigor • Random controlled trial (RCT) • At least 2 groups:  "treatment" and "non-treatment" • Assignment to the groups is random • "Quasi-experimental" (using a "matched" but non-random control group) • Like RCT but creates a non-treatment group • Pre- and post-analysis – uses administrative records (Rand)

15. General conclusions of National Academy (NA) review of PSH re: keeping homeless stably housed “Based on studies conducted over a 1- to 2-year period, PSH effectively maintains housing stability for most people experiencing chronic homelessness. Whether PSH can reduce chronic homelessness for these individuals for longer periods of time will only be known once the results of longer term studies are available.”

16. General conclusions from National Academy on improving health outcomes “Overall, except for some evidence that PSH improves health outcomes among individuals with HIV/AIDS, the committee finds that there is no substantial evidence as yet to demonstrate that PSH improves health outcomes…. However, while this was the inescapable finding based on an impartial review of the evidence available at the time of this assessment, the committee believes that housing in general improves health, and notes that PSH is important increasing the ability of some individuals to become and remain housed.”

17. General conclusions from National Academy on reducing costs “The committee examined studies that attempted to assess the cost-effectiveness of PSH and found that, at present, there is insufficientevidence to demonstrate that the PSH model saves health care costs or is cost-effective. Unfortunately, the literature on cost effectiveness of PSH is sparse; few randomized controlled studies have been conducted… However, PSH was designed with the primary goal of preventing and ending chronic homelessness and not for the purpose of accruing costs savings… The committee does not believe policy makers should expect that PSH would yield net costs savings, although some cost savings could be identified in specific studies such as those that exclusively focus on persons who are persistently high utilizers of emergency medical services systems.”

18. NA review of findings on “program characteristics” & PSH success • 2 housing options: single-site vs. scattered site “…there is good evidence from multiple studies that single-site and scattered-site supportive housing programs result in comparable levels of housing stability over follow-up periods of up to 2 years. There is less conclusive evidence with respect to health and other outcomes.” • Supported services – important but often poorly defined “..the existing literature lacks information on the type, intensity, frequency, or length of these services….Furthermore, there is no agreement on what the best supportive service models are among the different groups of individuals that are housed.”

19. A case study: Some descriptive statistics of the Rand study population • Mean age: 51.6 years • Male/Female shares: 65%/35% • Race/ethnicity • Black: 44% • Latino: 32% • White: 15% • All other: 9% • Chronically homeless share: 83% • Mean years of homelessness: 2.8

20. Health characteristics of Rand study population (shares) • Physical disabilities 35% • Behavioral health conditions • Serious mental illness 72% • Non-serious mental illness 70% • Substance abuse disorder 23% • Selected physical health conditions • Musculoskeletal 53% • High blood pressure 28% • Skin disease 27% • Diabetes 22% • Co-occurring medical conditions 88%

21. Rand study re:service utilization due to one year of PSH– selected statistical results (% change) Frequency of emergency room visits: -80.1%*** Days of inpatient stays: -61.0%*** Frequency of outpatient visits: -47.1%*** Frequency of behavioral health outpatient visits -44.1%*** *** indicates result is statistically significant at the 99% confidence level Reductions also occurred, but were not statistically significant, in other services: inpatient days for behavioral health, frequency of crisis stabilization service use.

22. Rand study result:  changes in total costs one year before and after PSH for highest cost services(% change) Inpatient -75.8%*** Outpatient -22.8%*** ER -66.3%*** Behavioral health outpatient -23.9%*** General Relief (LA County-specific $ assistance) -17.1%*** Jail 81.5%** Probation -28.5% ** & *** indicates result is statistically significant at the 95% & 99% confidence level, respectively

23. Rand study: annual changes in the LA County PSH “balance sheet” ($M) Pre-housing total services 33.9 Post-housing total services -13.7 Total gross savings 20.2 Cost of additional PSH services -13.4 Total net savings 6.8 Or, total outlays declined by ~20% (~ $7,640/year)

24. Results from the Rand study:  some evidence of improving (mental) health • Small sample: n = 83 • Survey tool: QualityMetrics SF-12v2 • 2 components: physical & mental • All-population norm = 50 • Outcomes after 12 months of PSH • Physical: 39 vs. 39 • Mental: 44 vs. 40

25. Conclusion by Rand researchers “Thus far, the program has successfully enrolled large numbers of individuals and has kept almost all of them in housing for a year while reducing their utilization of costly medical and mental health care…….. These findings suggest that HFH PSH could save money for Los Angeles County. However, the cost results have an important limitation: they measured only services associated with six county departments over a two-year period and are not a full accounting of all potential costs and benefits from the HFH PSH program. Research that employs more rigorous causal methods (i.e. that includes a comparison group) is needed before we can state conclusively that the dramatic changes observed in county services utilization prior to and following supportive housing are solely attributable to the HFH PSH program.”

26. NA review recommendation re: improving our understanding of health outcomes “The committee believes that stable housing has an especially important impact on the course and ability to care for certain specific conditionsand therefore the health outcomes of persons with those conditions. The committee refers to these conditions as “housing-sensitive conditions” and recommends that high priority be given to conducting research to further explore whether there are health conditions that fall into this category…. The evidence of the impact of housing on HIV/AIDS in individuals experiencing chronic homelessness may serve as a basis for more fully examining this concept.”

27. NA review recommendation re: improving our understanding of cost effectiveness of PSH • Need for more & better research “Incorporating current recommendations on cost-effectiveness analysis in health & medicine, standardized approaches should be developed to conduct financial analyses of PSH in improving health outcomes. Such analyses should account for the broad range of societal benefits achieved for the costs, as is customarily done when evaluating other health interventions.” • Still, NA found some positive evidence “Although the evidence is not strong, it suggests that PSH is cost-effective for those with persistent patterns of homelessness and serious mental illness.”

28. Lessons learned about evaluating PSH from the Rand study Essential: a data system that integrates, at a minimum, all local government-funded activities for the homeless. Involve researchers from beginning of project Try to set up the evaluation via a RCT Ideally, evaluate over a period longer than 1 year in PSH

29. Thoughts about applicability to expanding PSH in Benton & Franklin Counties  • Demand, albeit modest, for PSH seems to exist • But do the greater Tri Cities possess the requisite data infrastructure to track outcomes & therefore able to demonstrate success? • Can the “persistently high utilizers” be identified? • Can “medically-sensitive” conditions that are most amenable to PSH success be identified, despite the absence of best-practice consensus?

30. Questions? dpjones@ewu.edu 509.828.12465