CSH Los Angeles County 10th Decile Project

Intensive Case Management and Supportive Housing Targeted to

Homeless Frequent Hospital UsersInnovations Summit on Integrated Care

June 12, 2015

Our Mission

Improve lives of vulnerable

people

Maximize public

resources

Build strong, healthy

communities

Advancing housing solutions that:

Maximizing Public Resources

Public Systems

HousingHealth Care

Criminal JusticeChild Welfare

CSH collaborates with communities to introduce housing solutions that promote integration among public service systems, leading to strengthened partnerships and maximized resources.

Maximized Resources

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58 Counties in CAPopulation 40 M

Homeless Population 113,952

L.A. County: 88 Cities76 Emergency RoomsTotal Population 10 MHomeless Population 44,359

44,359 people, or 1 OUT OF EVERY 225 RESIDENTS,

are homeless in LA County

Los Angeles County Homeless Population

4

EMERGENCY

DEPARTMENTS

STREET

HOSPITAL INPATIENT

BEDS

SHELTERPSYCHIATR

IC HOSPITALS

JAIL

DETOX

Most homeless frequent users of crisis services:

1. Present complex, co-occurring social, health and behavioral health problems

2. Are not adequately served by mainstream systems of care

3. Demand more comprehensive, integrated interventions -including housing

5

The cycle of chronic homelessness and crisis services High costs and poor health outcomes

Chronically ill homeless individuals continually

cycle in and out of high-cost services,

yet health outcomes do not improve.

5

Randomized, control-group, pre-post, pilot evaluations

Housing is Health Care

2002 2008 2009 2011 2013

Bottom Line: The strongest healthcare intervention for homeless high utilizers is supportive housing.

Frequent User Initiatives in Los Angeles

PilotFrequent Users Systems Engagement (FUSE)$1 M over 2 years

Expansion10th Decile Project - Social Innovation Fund (SIF)$7.5M over 5 years Corp. for National & Community Service (CNCS)

2003 2008

2009

2011

2012

2013

2014

2015

2016

2017

Frequent Users of Health Services (FUHSI)

Scale UpHealth PlansAB 361 Health Homes1115 WaiverDHS FHSP

Economic Roundtable

“Where We Sleep”

Today

Los Angeles County Department Of Health Services

$18M FLEXIBLE HOUSING SUBSIDY

POOL• Launched Jan 2014• DHS: $13M, Hilton Foundation:

$4M• 10,000 SH subsidies 2014-17• ICM, PSH-Brilliant Corners• Bridge housing, Recup care

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Average Monthly Costs by Decile for Homeless Adults

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

Low

est

Decile

Secon

d D

ecile

Third

Decile

Fourt

h D

ecile

Fifth

Decile

Six

th D

ecile

Seven

th D

ecile

Eig

hth

De

cile

Nin

th D

ecile

Hig

hest

Decile

Probation

Sheriff mental healthjail

Sheriff medical jail

Sheriff general jail

LAHSA homelessservices

GR HousingVouchers

General Relief

Food Stamps

Paramedics

Public Health

Mental Health

Private hospitals-ER

Health Srv - ER

Health Srvoutpatient clinic

Private hospitals-inpatient

Health Srv hospital-inpatient

8Source: 2,907 homeless GR recipients in LA County with DHS ER or inpatient records

$6,529 per person per month

Crisis Indicator: Triage Tool for Identifying Homeless Adults in Crisis. Economic Roundtable. 2011.

Where We Sleep: Costs when Homeless and Housed in Los Angeles. Economic Roundtable. 2009.

10TH DECILE

Target Population

Chronically Homeless Frequent Users in the 10th

Decile• 10% highest-cost, highest-

need• Screening and outreach at

hospitals with triage tool• $78,348 in annual public costs

per person when homeless, including health care, criminal justice, GR

• $41,424 of cost paid by hospitals• 71% cost savings when in

supportive housing Savings can pay for SH Financial benefits for MCOs

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$3,452 per person per year

10th Decile Project Model for Health Care Delivery

Apr 18, 2023

10th Decile triage tool

highest-cost, highest-need 10% of homeless

individuals

Collaboration hospitals, FQHCs, homeless services

Health Homes intensive case

management/ care coordination

Permanent Supportive

Housinghousing navigation

and retention

PRIMARY CARE

BEHAVIORAL HEALTHSUBSTANCE ABUSESUPPORTIVE

HOUSINGNAVIGATORFREQUENT

USERS

The Glue: Intensive Case Management i.e., Care Coordination + Housing Navigation

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Apr 18, 2023

6 COMMUNITIES + 8 HOMELESS SERVICES PROVIDERS + 5 FQHCS + 15 HOSPITALS

CSH

Westside OPCC Venice Family Clinic

St. John’s Health Center

Santa Monica UCLA

Downtown

Homeless Health Care

LAHHCLA St. Vincent

Olympia Medical Center

Good SamHousing Works JWCH California

Hospital

Pasadena

Housing Works

Community Health Alliance

of Pasadena

Huntington Hospital

Homeless Health Care

LAHHCLA

Alhambra Medical Center

Boyle Heights

Housing Works JWCH White

Memorial

Glendale Ascencia NEVHC Glendale Memorial

Glendale Adventist

Verdugo Hills

SFV LAFH + SFVCMHC NEVHC

Mission Community

Hospital

Kaiser Woodland

Hills Kaiser

Panorama City

10th Decile Project Collaboratives

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• 71% male• 29% female

Sex

•43% African American•23% White•15% Latino•3% Asian/Pacific Islander•4% Other

Race

• Average: 48 years old• 68% > 46 years old

Age

• 29%Jail or probation

• 18 per person average in 24 months before referral

ER visits

• 7 per person average in 24 months before referral

Hospital admits

• 31 per person average in 24 months before referral

Hospital inpatient days

• 92%Chronic physical disability

• 71%Mental disorder

• 62% self-reportSubstance abuse

• hypertension• heart failure• diabetes• rheumatism• liver disease• venous embolism• chronic pulmonary

disease• schizophrenia• bipolar

disorder• depression• alcohol• drugs

Baseline Profile

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3/4 with co-occurring disorders

Half with tri-morbidities

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Apr 18, 2023 12

CSH 10th Decile Project Outcomes for Nonprofit Hospital Frequent Users

• Average cost avoidance per person: $54,106

Source: FUSE/SIF hospital cost data, 2011 - 2014

ER utilization down 71%Hospital readmissions down 84%

Inpatient days down 80%

ER costs down 67% Inpatient costs down 85% Total costs decreased 79%

Hospital Utilization/Cost Avoidance 10th Decile Project: 79% Average Decrease In Total Costs

ER visits IPT admits IPT days

7.9 6.9

25.4

2.3 1.1 5.2

Hospital Utilization Pre- and Post-Enrollmentaverage per person, n=77

12 mos before 12 mos in program

ER costs IPT costs Total cost

$6,124

$53,145

$68,118

$2,038 $7,892

$14,012

Hospital CostsPre- and Post-Enrollmentaverage per person, n=7712 mos before 12 mos in program

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DHS Outcomes for County Hospital Frequent Users

• Average cost avoidance per person: $32,000

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10th Decile Clients in HousingHousing Retention Rate = 94%

San Fernando Valley

Pasa

dena

GlendaleSan Fernando Valley

Downtown L.A.

No. H

ollywood

Glendale

ACA Requirements of Health Home Option, Section 2703

2 Chronic Conditions, 1 Condition & Risk of 2nd, 1 SMI

Can Target by Severity

MH/SU Tx

CM

Housing

Primary Care

Team :Primary Care,Behavioral Health, SUD, Social Service Providers

2 Years: 90% Federal, 10% State

Health Homes, ACA Section 2703California AB 361: “Health Homes” Bill (Mitchell)

Health Home = Virtual “Home” for Addressing the Whole-Person Needs of a Beneficiary with Complex, Chronic Conditions

AB 361 authorizes CA to create a Medi-Cal health home benefit.

Benefit: funding for services integrating care across medical, behavioral health, social services systems.

Requires DHCS to include as target populations:

FREQUENT HOSPITAL USER beneficiaries and

CHRONICALLY HOMELESS beneficiaries

Bill signed by Governor Oct 2013

Frequent Hospital User Beneficiaries

Chronically Homeless

Beneficiaries

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Health Home ServicesServices to Address “Whole-Person” Needs

COMPREHENSIVE CARE MANAGEMENT

CARE COORDINATION & HEALTH

PROMOTION

COMPREHENSIVE TRANSITIONAL CARE

INDIVIDUAL AND FAMILY SUPPORTS

REFERRAL TO COMMUNITY &

SOCIAL SERVICESHEALTH IT, DATA,

EVALUATION

OUTREACH & ENGAGEMENT

Definition of Health Home: An integrated, person-centered, and physical and behavioral service delivery system aimed at populations with complex, chronic conditions • fueled by exchange of health information, evidence-based practices and care coordination• intended to improve outcomes by reducing fragmented care and promoting patient-centered care.

For Complex Beneficiaries, Team Care is Better CareCoordination, collaboration, continuity enhance health services

Health Home Program Director

Dedicated Care Managers

Clinical Consultants

Community Health Workers

Housing Navigators

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Medical Homes: physician-centered, medically-

focused

Health Homes: beneficiary-centered, multi-disciplinary, whole-person care

Health Action

Plan (HAP)

Incorporating

Social

Services

DHCS Technical Work Groups Summer 2015

Structure: MCPs & CB-CMEs

Care Management: Network

Development

Data: Assessment, HAP, Reporting, Metrics

Rates: Eligibility, Tiers,

Staffing

Addressing Needs of Homeless HHP

Participants18

Health Homes Timeline• DHCS Technical Workgroups July-

August

• DHCS State Plan Amendment submission to CMS August 2015

• Jan 2016: Launch in 7 Coordinated Care Initiative (CCI) Counties

• Jul 2016: Launch in Other Counties Demonstrating Readiness