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

2. USA 78 Japan 83 Mongolia 67 Ethiopia 53 USA Homeless 46

6.  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

7.  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

8.  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

10.  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

12.  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)

13.  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

14. 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

15. Supportive Housing Cost-Effective Every Day

16.  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

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

18.  Creating homeless friendly health centers  Services in Supportive Housing  Respite care  Frequent ED user programs  Hospital discharge/care transition models  Veteran’s programs  Educate and enroll homeless in Medicaid

20.  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

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

22.  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

23.  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

24.  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