Targeting Supportive Housing to High-Cost/

Frequent Users of Public Systems

Richard Cho

NAEH 2011 Conference

July 13, 2011

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Corporation for Supportive Housing

CSH is a national non-profit organization that helps

communities create permanent housing with

services to prevent and end homelessness.

CSH advances its mission through advocacy,

expertise, innovation, lending, and grantmaking.

Lavelle’s Story

Lavelle has been arrested more than 150 times, largely for quality-of-life crimes

He suffers from schizophrenia, depression, and drug addiction

Has had inconsistent mental health care and multiple encounters with drug treatment programs

He has spent most of the last 12 years on a revolving door between streets, shelter, hospitals, and jail

He is wary of new people and mistrustful of service providers, and is often viewed as anti-social

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The Institutional Circuit of Homelessness and Crisis Service Systems

The “institutional circuit”:

– Indicates complex, co-occurring social, health and behavioral health problems

– Reflects failure of mainstream systems of care to adequately address needs

– Demands more comprehensive intervention encompassing housing, intensive case management, and access to responsive health care

Detox

Emergency Residential

Program

Jail

Shelter

Psychiatric Hospital

Emergency Room

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High Use of Public Services with Poor Outcomes

In many communities, there exists a subset of individuals who consume a disproportionate amount of health services with no improvements to health outcomes

Billings’ (2006) analysis of NYC Medicaid claims data found that:

– 20% of adult disabled patients subject to mandatory managed care account for 73% of costs

– 3% of patients accounting for 30% of all costs for adult disabled patients

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Why Target SH to High Cost / Frequent Users?

Moral Argument: “They have complex needs that are slipping through the cracks of service systems and should be prioritized for help.”

Economic/Efficiency Argument: “Targeting high-cost and frequent users can result in cost offsets to the public.”

The Governance/Reform Argument: “The institutional circuit shows that our public systems are broken. We need to break down silos and shift public spending towards proven solutions that work.”

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“Touching the Elephant in the Dark”

Government functions in specialized departments/agencies that each view problems in specialized ways

Multi-dimensional problems are therefore viewed in a fractured way

Each agency has only a piece of the larger story

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“When holding a hammer, everything looks like a nail”

Each government agency uses what limited tools and instruments it has at its disposal to try to fix problem, even when it know it is inadequate

Solutions become piecemeal, focused on only a part of the problem and therefore, ineffective

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The Creeping Institution

As solutions chase problems, an unintended consequence is the gradual expansion of the institution, at great costs and poor outcomes

Institution Client

The Solution: CSH’s Frequent User

Systems Engagement (FUSE) Initiative

FUSE Premise

Thousands of people with chronic health conditions cycle in and out of crisis systems of care and homelessness - at great

public expense and with limited positive human outcomes.

Placing these people in supportive housing will improve life outcomes for the tenants, more efficiently utilize public

resources, and likely create cost avoidance in crisis systems like jails, hospitals and shelter.

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Pillars and Steps of FUSE

Data-Driven Problem-Solving

Cross-system data match to identify frequent users

Track implementation progress

Measure outcomes/impact and cost-effectiveness

Policy and Systems Reform

Convene interagency and multi-sector working group

Troubleshoot barriers to housing placement and

retention

Enlist policymakers to bring FUSE to scale

Targeted Housing and Services

Create supportive housing and develop assertive recruitment process

Recruit and place clients into housing, and stabilize

with services

Expand model and house additional clients

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Cross-System Data Match Provides Recruitment List

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NAME CLIENT_ID DOC_LOS DHS_LOS SHELTER DOCFacility

Zeilinger, L. 9862966231 45 98 USICH EMTC

Hobson, B. 9862966248 64 132 DESC BBKC

Kanis, B. 2511910236 75 64 ComSol RMSC

Cho, R. 7890826000 23 156 CSH EMTC

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Assertive Recruitment Through Jail, Shelter, Hospital In-Reach

Courts

Jail/Prison

Street

Hospital

Detox

Alcohol/Drug Treatment

Shelter

Psychiatric Hospital

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Supportive Housing

Section 8 Housing Choice Vouchers (or State rental assistance programs) + Mobile Intensive Case Management Services

Unit set-asides in new supportive housing buildings or existing supportive housing with turnover

Providers trained in Motivational Interviewing, navigating criminal justice system, harm reduction, recognizing “symptoms” of incarceration

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“Systems Change” Through Case Coordination

Monthly implementation monitoring meetings to track recruitment, housing placement, housing retention, and recidivism prevention

Case conference and intervention in cases of re-arrest or re-hospitalization

Puts supportive housing provider at center of “system of care”

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Measure Outcomes and Cost-Effectiveness

Crisis services use ($) 2 years before FUSE

— Crisis services use ($) 2 years after FUSE

— FUSE cost over 2 years

Net Savings/(Cost) of FUSE over 2 years

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New York City FUSE

Demonstration program designed to test whether PSH with enhanced engagement services can break cycle of homelessness and incarceration among individuals who are known “frequent flyers” of jail and shelter

Supportive housing with “front-loaded” intensive case management services for 190 frequent users of jail and shelter, identified through pre-generated data match

Frequent User Case Study

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DOC

Neither System

Implementation through Collaboration

Partner Role

NYC Dept of Correction Data matching, program oversight, policy advocacy, service enhancement funding, facilitate jail in- reach

NYC Dept of Homeless Services Data matching, program oversight, policy advocacy, service enhancement funding, facilitate shelter in-reach

NYC Dept of Health and Mental Hygiene

Services and operating funding and program oversight

CSH Program design, assembled and coordinated funding, program oversight and troubleshooting, TA/training,

NYC Housing Authority / Housing Preservation and Development

Provide Section 8 vouchers

JEHT Foundation / Langeloth Foundation

Provided funding for service enhancements and evaluation

NYC Office of Management and Budget

Program oversight

John Jay College / Columbia University

Program evaluation

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FUSE I Resources and Models

50 NYCHA Section 8 vouchers (Project Based)

50 existing single-site supportive housing unit set-asides

Supportive services funded through other existing sources (e.g. COBRA, HUD)

$650,000 from JEHT Foundation for service enhancements + $80,000 for training and TA

A. 50 Single-site (Congregate) supportive housing with front-loaded intensive services

B. 50 Scattered-site supportive housing with front-loaded intensive services

---------------------------------------------

Total: 100 units of supportive housing with FUSE

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FUSE II Resources and Models

40 NYCHA Section 8 vouchers (Project Based)

20 HPD Section 8 vouchers (Tenant Based)

16 NY/NY subsidies and services

17 existing supportive housing unit set-asides

$604,500 from NYC DOC and DHS for service enhancements

$250,000 from Langeloth Foundation for evaluation

A. 17 Single-site (Congregate) supportive housing with front-loaded intensive services

B. 73 Scattered-site supportive housing with front-loaded intensive services

---------------------------------------------

Total: 90 units of supportive housing with FUSE

Providers and Units

Provider Round I Units

Round II Units

Single / Scattered

BRC 3 -- Single

Brooklyn Community Housing and Services

18 1 Single

Community Access 19 -- Single

The Bridge 5 -- Single

Women’s Prison Association 3 -- Single

Common Ground 26 19 Scattered

The Jericho Project 12 5 Single

Palladia 14 19 Scattered

CAMBA -- 10 Single

Pathways to Housing -- 36 Scattered

TOTAL 100 9023

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NYC Frequent Users of Jail and Shelter Phase I Evaluation Results

Two years after placement into housing with services, tenants have experienced:

– 91% housing retention rate

– 92% reduction in use of homeless shelters

– 53% reduction in use of city jails

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Jail-Shelter Cost Offsets from FUSE

DOC DHS

FUSE Comparison FUSE Comparison

Average Days Pre 52.8 45.0 58.2 26.6

Average Days Post 25.0 36.0 4.6 7.0

Average Days Avoided 27.8 9.0 53.6 19.6

% Days Avoided 53% 20% 92% 74%

% Reduction Attributable to FUSE 33% 18%

Days Reduced Attributable to FUSE 17.2 10.7

Per Diem Jail/Shelter Cost $129 $68

Annual Cost Offset Per Person $3,586 $3,645

Adjusted Annual Cost Offset Per Person $2,224 $729

Annual DOC & DHS Cost Offset Per Person

$7,231

Other FUSE Replications

Implementation Cook County, IL Hennepin County, MN Connecticut Seattle, WA Denver, CO Washington, DC

Planning Franklin County, OH Newark, NJ Detroit, MI Los Angeles, CA Richmond, VA Austin, TX

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Improved Understanding of Problem

Multi-agency, cross-sector planning and analysis led to reframing of problem:– Not “career criminals” or jail shelter discharge, but an “institutional circuit” across multiple systems

Shift from finger-pointing to shared ownership of problem

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Development of Comprehensive Solution and Pooling of Resources

Solution was not improved jail discharge planning or improved shelter services, but supportive housing to address housing, criminogenic, and behavioral health service needs at once

Resources pooled from multiple sectors and systems (corrections, homeless services, housing, behavioral health, and philanthropy)

Joint government-community implementation process allows for troubleshooting at all levels

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Creating Person-Centered Systems of Care and Response

Shifting resources from institutions to housing and services

Changing the housing prioritization paradigm from “first come, first serve” to reaching most needy and costly

Shift housing provider role from passive “tenant selection” to active “in-reach and recruitment”

For More Information

Richard Cho

Director, Innovations & Research

Richard.cho@csh.org

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