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Expanding and Financing Supportive Housing In Los Angeles
Joshua Bamberger, MD, MPH
San Francisco Dept. of Public Health
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
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