Expanding and Financing Supportive Housing In Los Angeles

Joshua Bamberger, MD, MPH

San Francisco Dept. of Public Health

josh.bamberger@sfdph.org

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

Financing Supportive Housing

Tale of 3 Buildings

• Plaza

• Folsom-Dore

• Empress

Plaza Apartments

• $30 million construction• Private investors receiving

tax credits from Feds• Business model includes

resident rent, rent subsidies

•

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

Healthcare utilization pre/post Plaza

35 50189

3725

348

1467

14 40125 124

246

1389

0

500

1000

1500

2000

2500

3000

3500

4000

Psyc ER Psyc Inpt Med ER SNF Med Inpt Outpt

Sites of Service

days

1 yr. Before

1 yr. After

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

Folsom Dore Healthcare Utilization

12

52

93

269

400

281

0 0

40

113

66

226

0

50

100

150

200

250

300

350

400

450

PSY ED PSY ID Med ED Med ID SNF OA

Sites of Service

Day

s o

f S

ervi

ce

One year before

One year after

Empress Hospital days

158

74

314

532

73

48

131

160

0

100

200

300

400

500

600

Med ED Psyc ED Med Inpt Psych Inpt

Day

s Year before

Year after

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

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

Financing Healthcare Services

Mainstream Healthcare Funding Sources

• Medi-Cal billing- FQHC– Historic ties to OEO/War on Poverty

• HRSA Community Health Centers

• Other

• Opportunity to end homelessness

FQHC

• Must apply to both Feds for health center status and State for encounter rate

• Rate determined by total cost/total patients

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

Types of providersAllowed 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)

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

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

Housing and Urban Health Clinic

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

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

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

Cost

• Annual Budget: $2.1 million

• Annual Revenue: $2.3 million

• Need grant money for innovation

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

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

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

josh.bamberger@sfdph.org