HOMELESSNESS AND HEALTHCARE: STRATEGIES FOR SUCCESS North Carolina Coalition to End Homelessness securing resources encouraging public dialogue advocating for public policy change Susanna Birdsong, Program Director

Homelessness in North Carolina  Who’s Homeless?  Point in Time Count (January 2009) Over 12,700 North Carolinians 9,125 individuals (6813 men, 2312 women) 1,238 families (3621 persons,1376 adults, 2245 children) Subpopulations (self-reported, under-reported) Chronically Homeless = 1342 Mentally Ill= 1639 Substance Use Disorder=3332 Veterans = 940 Persons with HIV/AIDS = 203 Victims of Domestic Violence = 1131 Unaccompanied Youth = 85  Get the stats for your community:

 Households may become homeless for a variety of reasons (inadequate income, lack of access to health care, mental illness, substance use, domestic violence, etc).  The key difference between individuals and families who become homeless and those that don’t is the existence of a healthy support system. Why are people homeless?

Homelessness + Health North Carolina Coalition to End Homelessness  Several studies have found that one-third to one-half of homeless adults have some form of physical illness—rates of mental illness are comparable.  At least half of homeless children have a physical illness and they are twice as likely as housed children to have such illnesses.  One-quarter of homeless adults reported that their poor health prevented them from working or going to school.  Rates of mortality are three to four times higher in the homeless population than they are in the general.

Three Keys to Ending Homelessness  Affordable Housing  Develop new housing, provide rental subsides  Appropriate Services  Healthcare, Mental Health, Chemical Health, Employment, etc.  Adequate Income  Employment, mainstream benefits

New Research & Data  Chronic Homeless and Housing First Research = Housing Plus Services is effective and cost-efficient  New research shows effectiveness of Housing Plus Services approach for families  Housing PLUS Services can work for all individuals and families who experience homelessness Difference = Length of Assistance

Evidence-based Practice  Communities across the country have found success:  New Approaches in Prevention  Permanent Supportive Housing  Decreases in Chronic Homelessness  New Rapid Re-Housing Programs

Ten-Year Plans to End Homelessness  Bringing new energy and resources to the table  Redefining the conversation  Demonstrating success through new approaches  Garnering new support and attention from the community and leaders

Communities Implementing 10-Year Plans to End Homelessness  Asheville/Buncombe  Chapel Hill/Orange  Charlotte/Mecklenburg  Durham/Durham  Fayetteville/Cumberland  Greensboro/Guilford  Greenville/Pitt  Raleigh/Wake  Shelby  Wilmington/Brunswick/ New Hanover/Pender  Winston-Salem/Forsyth

Creating a New System  Right now, we have a once-in-a-lifetime opportunity to change how we address homelessness  New legislation  HEARTH Act  Recovery Act: HUD’s Homelessness Prevention & Rapid Re-Housing Program

Our Current System Emergency Shelter Child Care Mental Health Substance Abuse Family Supports Employment Education 1.Experience housing crisis 2.Move from system to system seeking support 3.Lose Housing 4.Enter Emergency Shelter 5.Address barriers to housing while in the shelter or transitional housing

A New Approach Housing Stabilization Child Care Mental Health Substance Abuse Family Supports Employment Education Emergency Shelter 1.Experience housing crisis 2.Reach out for support 3.Providers assess for housing risk and make referral to housing stabilization services 4.Based on client need, appropriate services are provided (e.g. landlord mediation, short-term rental assistance, housing search, rapid re-housing, and wrap- around services) 5.Client may need to stay at a shelter while receiving stabilization services

Engagement  First things first…client engagement!  Homeward Bound of Asheville: Strategies for success

Homelessness + Healthcare  SOAR  Planning/ Respite Care  Permanent Supportive Housing + Healthcare integration

SOAR  SSI/SSDI Benefits  Income  SSI=Medicaid  SSDI=Medicare

The Challenge  Path to recovery is extraordinarily challenging when basic needs are unmet  SSI/SSDI application and disability determination process can seem complex  Disconnect between the experience of homelessness and the disability application process  Medical information is often very incomplete  Only about 15% of those who apply are typically approved on initial application  Appeals take years and many potentially eligible people give up and do not appeal  Without Health Insurance, individuals use Emergency Department as Primary Care

The Solution: NC SOAR  Focuses on the hard-to-serve, uninsured individuals  Approach to gain approval on initial disability application  Case Managers play increased role to bridge communication gap  Works with medical professionals to improve documentation  Encourages individual to access appropriate care  Allows for mobility and follow-up

Disability Determination Services: Main Question Does this illness (or illnesses) keep the person in question from being able to engage in substantial gainful activity?

SOAR Critical Components  Client Engagement and Respect  SSA-1696 Representative  Treatment provider relationships  Medical records collection  Medical Summary Report, co-signed by M.D. or PhD. Psychologist

Cost Savings  In Covington, KY, a local hospital partially funded the local SSI outreach project recouping its initial investment in less than a year by recovering uncompensated care from Medicaid  San Francisco Dept. of Public Health estimates that for every $1 invested in SSI outreach, they recoup $5 in Medicaid reimbursement for uncompensated care  In one year in Baltimore, 20 newly approved SSI recipients accounted for $300,000 in Medicaid reimbursable care from one hospital system.

SOAR Outcomes CityPercentage Approved Baltimore96% Nashville98% Philadelphia100%

NC SOAR Outcomes Average time between completion of application and determination 3 months Average length of time homeless2 years Percentage of applications approved74%

Dedicated SOAR Workers  Asheville/Buncombe  Winston-Salem/Forsyth  Greensboro/Guilford  Durham  Gastonia  Greenville/Pitt  Wilmington/New Hanover

Discharge Planning In order to have a successful discharge plan and reduce recidivism:  Follow-up Services in the Community  Appropriate Placements for Discharge

Respite Care Basics  Medical respite care is acute and post-acute medical care for homeless persons who are too ill or frail to recover from a physical illness or injury on the streets, but who are not ill enough to be in a hospital.  Fills the gap between an inpatient hospital bed and the unstable environment that is homelessness.  Necessary part of the continuum of healthcare for the homeless.

Respite Care Video 

Permanent Supportive Housing + Healthcare Integration  Encourages appropriate use of healthcare services (decreases Emergency Department use & hospitalizations)  Housing increases stabilization and allows households to follow healthcare plan  Typically costs of healthcare are increased in first two years as individuals begin to seek care for chronic conditions, then decrease dramatically

Permanent Supportive Housing + Healthcare Integration  Investment in Permanent Supportive Housing Saves [Healthcare] Resources!  Hospitals/Funders beginning PSH funding initiatives

Permanent Supportive Housing + Healthcare Integration  Mt. Sinai Hospital in Chicago  In 2002…  Social Workers with varying degrees of knowledge and relationships with housing, respite and shelter providers  Long waits and many requirements to get into a housing unit  Most housing units require 6 months+ sobriety  High frustration with lack of resources for housing and/or safe discharge  Hospitals/Funders beginning PSH funding initiatives

Permanent Supportive Housing + Healthcare Integration  Mt. Sinai Hospital Con’t.  In 2003…  Partnership between the hospital, respite care provider and permanent supportive housing providers emerged  Funding from private funder + hospital  Hospital Respite Care Permanent Housing  Research=Randomized Control Trial (over 400 homeless patients)

Permanent Supportive Housing + Healthcare Integration  Mt. Sinai Hospital Con’t.  Results of Intervention group:  24% fewer ED visits  29% fewer hospitalizations  3 times more likely to achieve stable housing at 18 mo. Follow-up (66% v 21%) and had fewer housing changes  Unintended finding of much lower use of nursing home day

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Get Involved, Contact Us NCCEH Denise Neunaber, Executive Director Susanna Birdsong, Program Director Nancy Holochwost, Communications Coordinator