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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

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expanding and financing supportive housing in los angeles

Expanding and Financing Supportive Housing In Los Angeles

Joshua Bamberger, MD, MPH

San Francisco Dept. of Public Health

josh.bamberger@sfdph.org

overview
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
tale of 3 buildings
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

Plaza Apartments
costs
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
is homelessness cheaper than housing
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

health cost reduction first year
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
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
mainstream healthcare funding sources
Mainstream Healthcare Funding Sources
  • Medi-Cal billing- FQHC
    • Historic ties to OEO/War on Poverty
  • HRSA Community Health Centers
  • Other
  • Opportunity to end homelessness
slide15
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
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 providers allowed 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)

Types of providersAllowed Not Allowed
satellites
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
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
huh clinic funding
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
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
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
slide24
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

Comparison of HUH and LA HCH
recommendations
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
conclusions27
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