expanding and financing supportive housing in los angeles l.
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Expanding and Financing Supportive Housing In Los Angeles

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

  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

  7. 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

  8. 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

  9. 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

  10. Financing Healthcare Services

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

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

  13. 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

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

  15. 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

  16. 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

  17. Housing and Urban Health Clinic

  18. 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

  19. 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

  20. 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

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

  22. 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 Comparison of HUH and LA HCH

  23. 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

  24. 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

  25. josh.bamberger@sfdph.org