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Expanding and Financing Supportive Housing In Los Angeles Joshua Bamberger, MD, MPH San Francisco Dept. of Public Health [email protected] 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 l.jpg

Expanding and Financing Supportive Housing In Los Angeles

Joshua Bamberger, MD, MPH

San Francisco Dept. of Public Health

[email protected]


Overview l.jpg
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



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Tale of 3 Buildings

  • Plaza

  • Folsom-Dore

  • Empress


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$30 million construction

Private investors receiving tax credits from Feds

Business model includes resident rent, rent subsidies

Plaza Apartments


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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


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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


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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


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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



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Mainstream Healthcare Funding Sources

  • Medi-Cal billing- FQHC

    • Historic ties to OEO/War on Poverty

  • HRSA Community Health Centers

  • Other

  • Opportunity to end homelessness


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FQHC

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

  • Rate determined by total cost/total patients


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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


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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


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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


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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



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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


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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


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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


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Cost

  • Annual Budget: $2.1 million

  • Annual Revenue: $2.3 million

  • Need grant money for innovation


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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


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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


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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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