Targeting Super-Utilizers: The Roles of Supportive Houisng and Case Management / Peer Support Presenter: Nolan Nelson Health Care for the Homeless Supervisor Family Health Centers, Inc.
Phoenix Health Center Program of Family Health Centers, Inc. in Louisville, KY Began in 1988 State licensed and Joint Commission accredited $4 million budget: Bureau of Primary Health Care (HCH) HUD Substance Abuse & Mental Health Services Administration (SAMHSA) 45 employees
Phoenix Health Center Comprehensive Care: Primary Care Clinic Health Outreach Dental Care Respite Care Mental Health Services Social Services Outreach Case Management Substance Abuse Treatment SOAR Permanent Supportive Housing Coordinated Assessment 5,000 patients and 31,000 visits in 2013
FHC s Housing First Programs SAMHSA I (Grants to Benefit Homeless Individuals): Louisville Housing First Project for Homeless Adults 2008-2013 $2 million ($400,000/year) PSH + supportive services for homeless 62 housing vouchers: 42 HUD PSH + 20 Shelter+Care Grant Partners: Louisville Metro Government St. John Center St. Vincent de Paul Seven Counties Services Wellspring SAMHSA II (Cooperative Agreements to Benefit Homeless Individuals): Louisville Cooperative Housing First Project 2011-2014 $1.5 million ($500,000/year) PSH + supportive services for chronically homeless 75 housing vouchers: 70 Housing Choice, 5 Shelter+Care Grant Partners: Bridgehaven Louisville Metro Government Louisville Metro Housing Authority St. John Center St. Vincent de Paul Seven Counties Services Wellspring
Dr. Jim O Connell Boston Health Care for the Homeless
Why Are Our Neighbors Dying?
How to Respond? Jim O Connell, The painfully obvious lesson for me has been the futility of solving this complex social problem solely with new approaches to medical or mental health care I dream of writing a prescription for an apartment, a studio, an SRO, or any safe housing program, good for one month, with 12 refills.
Prescription? Housing!
We Had Our Name
Client Demographics: Rx Housing Total Housed: 104 Chronically Homeless: 100% Mean Age at Intake: 48 Gender: 88% M, 12% F Prior Housing: 54% shelters, 46% street/outdoors Chronic Mental Disorder: 95% Chronic Substance Use Disorder: 77% Co-Occurring Mental + Substance Disorders: 77% Chronic Health Problem: 83%
Targeting Super-Utilizers FHC Phoenix received bonus grant through Louisville Continuum of Care (HUD) Program started Jan 1, 2013 18 permanent supportive housing vouchers All slots reserved for super-utilizers All referrals came directly from University of Louisville Hospital s Emergency Department (ULH ED)
Housing First Model Referrals did not have to prove housing readiness in order to be eligible for housing Referrals did not have to prove 90 days clean and sober related to substance use Referrals did not have to prove 90 days treatment compliance related to mental illness or physical illness Clients moved directly from the streets or emergency shelter to an apartment of their own
Housing Readiness Model Permanent Housing Transitional Shelter Emergency Shelter Outreach
Housing First Model Permanent Housing Outreach
Housing First, continued Once housed, clients choose from a menu of services and treatment options: Substance use treatment (detox, residential, outpatient) Mental health treatment (meds, therapy) Crisis stabilization Psychosocial rehabilitation Small groups (activities, life skills, Seeking Safety, LGBT) Case management Peer support
Housing First, continued Client choice! Participation in services / treatment is not required 3 rules of Housing First model Clients must pay rent as required Clients must abide by the terms of their lease Clients must remain in regular contact with their case manager
Maslow s Hierarchy
Case Management Usually a social worker (MSW / MSSW) Link client with FHC Phoenix as PCP Strategize how to access ongoing medical care: using ED when necessary, using PCP when necessary Home visits as needed (monthly required, one participant receives daily home visits to assist with medication management) Coordinating care Transporting clients to appointments Enrolling clients in entitlement benefits (SNAP, Medicaid) Applying for SSI (SOAR) most did not have SSI at referral Reviewing available small group options Goal setting, treatment plans
Peer Support In world of permanent supportive housing, consumers with real-life experience = called Peer Support Specialists In world of health care, consumers with real-life experience = called Health Navigators? Why? Recovery focus Different dynamics (vs. professional staff) More informal
Rx: Housing Peer Support Groups
The Power of Peer Support Peer Specialists inform the work of the team Peer Specialists challenge our assumptions of what recovery means Peer Specialists foster empathy and understanding Bring clarity to the words client rights Clients relate to someone who has Been There, Done That More authentic relationships, greater honesty, and less shame Peer Specialists challenge stereotypes
Case Management & Peer Support Broadens and strengthens the array of services Improves client satisfaction Contributes to the development of a more authentic organization Sends a strong message to our clients, our staff, and the community that the agency believes in recovery
Outcomes: Housing Stability All Clients (N=135) Current Clients (N=79) Exited Clients (N= 56) 0-6 months 14 (10%) 4 ( 5%) 10 (18%) 7-12 months 21 (16%) 6 ( 7%) 15 (27%) 1-2 years 47 (35%) 33 (41%) 14 (25%) 2-3 years 17 (13%) 6 ( 8%) 11 (20%) 3-4 years 28 (21%) 22 (28%) 6 (11%) 4+ years 8 ( 6%) 8 (10%) HUD Goal: 77% stay in Permanent Supportive Housing more than 6 mos. Our Outcome: 90%
Outcomes: Income # with employment income has decreased # with Disability income has increased by 94% 50 SAMHSA-I clients received SSI/SSDI benefits as a result of our SOAR work resulting in $420,000 in annual income
Outcomes: Substance Use Mean days of alcohol use decreased 34% Number of daily alcohol users decreased 43% Means days of binge use decreased 53% Number of daily binge drinkers decreased 60% Participants reporting illegal drug use decreased 10% Mean days of drug use decreased 33% Participants using Crack Cocaine (most commonly used drug at entry) decreased 83% * Outcomes based on data from 54 participants with 24-month GPRA (Government Performance Results Act) surveys, from intake to 24 months. Outcomes are self-report of last 30 days use.
Outcomes: Mental Health Participants reporting daily depression decreased 69%. Participants reporting daily anxiety decreased 74%. Participants reporting daily impaired brain function decreased 37%. Participants reporting being extremely bothered by psychological/emotional problems decreased 75%. 38% of participants reported an increase in attendance at support groups. * Outcomes based on data from 54 participants with 24-month GPRA (Government Performance Results Act) surveys, from intake to 24 months. Outcomes are self-report of last 30 days use.
Outcomes: Criminal Activity & ED Usage Number of participants arrested decreased 56%. Mean number of arrests decreased 66%. Number of participants utilizing an ER decreased 36%. * Outcomes based on data from 54 participants with 24-month GPRA (Government Performance Results Act) surveys, from intake to 24 months. Outcomes are self-report of last 30 days use.
Program Challenges Clients continue living in homeless culture Housing Vouchers Time between Entry and Housing: SAMHSA I: 35 days SAMHSA II: 77 days Red Tape Termination of clients Landlords Show benefits of program Annual appreciation breakfast Staff/community buy-in for Housing First Targeting of most difficult clients Education at state and local level
Recommendations Identify your super-utilizers Find partners in your local HUD Continuum of Care Consider a partnership where a Permanent Supportive Housing program takes referrals directly from your clinic or Emergency Department Allocate some money for Case Managers and Peer Supporters Investing some money in case coordination can actually save money for your clinic / ED / MCO down the road Track outcomes Watch people get better
Contact Information Nolan Nelson, PSH Supervisor nnelson@fhclouisville.org Andy Patterson, HCH Director apatterson@fhclouisville.org