1. Expanding and Financing Supportive Housing In Los Angeles Joshua Bamberger, MD, MPH San Francisco Dept. of Public Health josh.bamberger@sfdph.org

2. Overview Financing supportive housing –Comparing buildings and services Model of providing healthcare for housed people –Integration of mental health and medical services –Mainstream revenue to pay for services

3. Financing Supportive Housing

4. Tale of 3 Buildings Plaza Folsom-Dore Empress

5. Plaza Apartments $30 million construction Private investors receiving tax credits from Feds Business model includes resident rent, rent subsidies

6. Costs $ 448,636 /yr in rent subsidies Sliding scale rent- 50% income @$350/month $ 459,830 /year in support services contract $150,000/yr in on-site medical staff $1,058,000 annual public expenditure $445,000 in rent $1,417/client/month $1.5 million annual budget

8. Is Homelessness Cheaper than Housing? Total Public Health Costs to be Homeless $1.9 million Total Public Health Costs to be Housed $1.2 million

11. Health cost reduction first year Plaza –$ 1,709,000 total; $20,105 per resident Folsom Dore –$521,000 total; $20,864 per resident Empress (not including SNF) –$ 943,500 total; $11,100 per resident

12. Conclusions Increase housing stability/decrease costs when –Mixed population buildings –High concentration of seniors –High quality architecture and apartments –Neighborhood with less drug use/sales –Case managers can achieve tasks Why? Trauma

13. Financing Healthcare Services

14. Mainstream Healthcare Funding Sources Medi-Cal billing- FQHC –Historic ties to OEO/War on Poverty HRSA Community Health Centers Other Opportunity to end homelessness

15. FQHC Must apply to both Feds for health center status and State for encounter rate Rate determined by total cost/total patients

16. FQHC- billing (cont’d) Patient must have Medi-Cal Rate for point of service by licensed providers No limit on length of time per visit No more than one visit/day for Primary Care No more than 2 visits/month for other care

17. Types of providers Allowed Not Allowed MD, DO NP/PA Psychiatrists Psychologists LCSW (2/month) Acupuncture (for SA) Podiatry Dentists RN MFT Case managers Med Assistance MSW (not licensed)

18. Satellites Can open pretty much anywhere Must not be open more than 20hrs/week Must treat pts enrolled in home clinic as PC Need Fire Marshall and state approval Include in scope of work

19. Components of High Productivity Clinical Functions Low support staff to provider ratio High Medi-Cal Penetration Mix of drop in and appointment Variety of staff skill set and specialties Adherence assistance One stop shopping

20. Housing and Urban Health Clinic

21. HUH Clinic Funding FQHC granted as part of Federal Grant Functioned as satellite as HCH site Used year of satellite function to come up with cost report Made estimates of staff time doing PC Received 80% of requested rate $202.40 per visit

22. HUH Clinic Staffing 10 mid-levels (2 psych NP) 1 FT MD 1 Part-time Med Director Clinic Director is NP 5 Full or part time psychiatrists (3 FTE) 1 RN, 1 Americorp, 1 EW, 1 Clerk Adherence program: 1 SW, 1 RN, 1 NP

23. Components of Model First door is right door- crossover of med and psych Build on relationship Reduce patient waiting time Give staff the opportunity to do what they are trained to do Staff set length of visit/mix of drop-in, appointment Embrace vicarious trauma

24. Cost Annual Budget: $2.1 million Annual Revenue: $2.3 million Need grant money for innovation

25. Comparison of HUH and LA HCH LA HCH Medi-Cal uptake: 10% FQHC rate: $120 High support staff to clinician ratio Huge homeless health demand Silo’d mental health and medical care HUH Medi-Cal update: 80% FQHC rate: $202 Low support staff to clinician ratio Large pop in supportive housing Integrated mental health and medical

26. Recommendations Invest in SSI/MediCal eligibility resources Use FQHC to hire Behavioral Health staff Increase Medi-Cal FQHC rate Set up clinic centrally to serve all people in supportive housing

27. Conclusions Mainstream funding can support clinic services Local funds to support rent subsidies and on- site services Decrease in downstream $ is greater than public expenditures- argument for day rate

28. josh.bamberger@sfdph.org