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Health Care for the Homeless Training Hawaii Primary Care Association June 27, 2013 Brenda Goldstein, MPH bgoldstein@lifelongmedical.org

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USA 78 Japan 83 Mongolia 67 Ethiopia 53 USA Homeless 46

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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

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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

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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

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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

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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)

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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

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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

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Supportive Housing Cost-Effective Every Day

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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

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Change is Possible CA Frequent User 2 Year Results Medicaid Population *Indicates statistically significant

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Creating homeless friendly health centers Services in Supportive Housing Respite care Frequent ED user programs Hospital discharge/care transition models Veterans programs Educate and enroll homeless in Medicaid

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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

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HUD grant opportunities Managed Care Contracts Hospital Contracts FQHC billing for behavioral health services Partnering with specialty mental health

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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

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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

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