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Health Homes for the Homeless: National and Local Opportunities. Health Care for the Homeless Training Hawaii Primary Care Association June 27, 2013 Brenda Goldstein, MPH Life Expectancy. Nationally. Hawaii 12 – 15,000 annually 6,000 on any given day

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health homes for the homeless national and local opportunities

Health Homes for the Homeless: National and Local Opportunities

Health Care for the Homeless TrainingHawaii Primary Care Association

June 27, 2013

Brenda Goldstein, MPH



  • 12 – 15,000 annually
  • 6,000 on any given day
  • 23.5 – 39% are children
  • 17 – 42% are employed full time
  • 37% are Native Hawaiian
health issues
  • Homelessness
  • Advanced chronic disease – cancer/heart disease
  • Drug/alcohol addiction
  • Trauma
  • Serious mental illness
  • Poor nutritional status
  • Dental problems
  • Pregnancy/Youth
    • Low birth weight
    • Developmental delays
    • Emotional problems
costs of homelessness
Costs of Homelessness
  • Hospitalizations/re-hospitalizations
    • Average 4 days longer inpatient ($2,414) attributable to homelessness
  • Incarcerations
    • For mental health, drug and alcohol use related behaviors or simply for sleeping on the street or loitering
  • Emergency Services (ambulance, ER use)
  • Increased costs of unmanaged chronic disease
national trends
National Trends
  • Affordable Care Act: Expanded Coverage and Access
  • Medicaid Health Home Funding Opportunity for States
  • Triple Aim
    • Improve health and reduce mortality
    • Improve the experience for patients and quality of care
    • Control costs
  • Bending the Cost Curve
    • Reduce avoidable ED visits, hospital admissions/re-admissions
    • Avoid unnecessary nursing home stays
    • Focus on small number of consumers with highest cost
  • Patient Centered Health Homes

Better health care for people experiencing homelessness is a strategy for achieving these goals

health homes for the homeless
Health Homes for the Homeless
  • Model and payment to support intensive services
  • Flexible service models
    • Who provides care (non-licensed staff can be highly effective)
    • Where care is provided (office, home, streets)
    • What “care” is (medical, psychosocial, flexible funds)
  • Fast access to supportive housing and other housing resources
  • Linkages to benefits
practical approaches
Practical Approaches
  • Integrated team approach
  • High frequency of interaction: need determines intensity of services
  • Strong linkages to community-based services, especially housing
  • Low Caseloads
  • Non-licensed staff can be the most effective case managers
  • Close communication with partners (primary care, behavioral health, benefits advocates, ED, discharge planners)
healthcare and housing emerging models
Healthcare and Housing: Emerging Models
  • Housing First
  • Rapid re-housing
  • Health Centers and HCH programs obtain housing resources for homeless clients
    • Partnerships with non-profit housing providers/public housing authorities
    • Align resources for housing, health care, and behavioral health
  • Prioritize access to permanent housing
    • Chronic homelessness
    • Vulnerability Index
    • Frequent users of crisis services
    • Family reunification
what is supportive housing
What Is Supportive Housing?

Permanent, affordable housing

with combined supports for independent living

  • Each tenant may stay as long as rent is paid and compliance with terms of rental agreement
  • Affordable - tenant pays no more than 30-50% of household income
  • Access to support services, but participation is not required
  • Different housing options are available
  • Housing First models provide access for people with high risk behaviors and long histories of homelessness

Supportive Housing

Cost-Effective Every Day

supportive housing making the case
Supportive Housing: Making the Case
  • Reduces costly care
    • 29% fewer inpatient admits and 24% fewer ED visits in Chicago
    • 56% fewer ED visits and 44% fewer inpatient admits in San Francisco
    • 77% fewer inpatient admits and 60% fewer ambulance rides in Maine
  • Improves health outcomes
    • Access to primary care and engagement in recovery services
    • Medication adherence and enhanced motivation to change
    • Improved health indicators for HIV + patients
    • Reduced drug/alcohol use
    • Improved mental health status
change is possible ca frequent user 2 year results medicaid population
Change is PossibleCA Frequent User 2 Year Results Medicaid Population

*Indicates statistically significant

health center opportunities
Health Center Opportunities
  • Creating homeless friendly health centers
  • Services in Supportive Housing
  • Respite care
  • Frequent ED user programs
  • Hospital discharge/care transition models
  • Veteran’s programs
  • Educate and enroll homeless in Medicaid
  • FQHCs - desirable partners
  • Healthcare:
    • linked to housing
    • embedded in mental health service sites
    • staff located in supportive housing
    • provided at shelters, transitional housing, board and care
  • Home visits
  • Mobile/street services
financing models
Financing Models
  • HUD grant opportunities
  • Managed Care Contracts
  • Hospital Contracts
  • FQHC billing for behavioral health services
  • Partnering with specialty mental health
challenges for clinics
Challenges for Clinics
  • High risk patients impact clinic productivity
  • Staff training to serve the population
  • Cultural differences when working collaboratively with housing providers
  • Clients need intensive, extended follow up – strain on resources
policy issues
Policy Issues
  • Payments to primary care for intensive services and incentives for reducing overall cost
  • Managed care plans adopting appropriate care and reimbursement models
  • Case management as a recognized “medical” service
  • Eliminate barriers to qualify for SSI/Medicaid
  • Housing subsidies as cost effective health benefit
  • Discharge policies and funding for medical respite
  • National Health Care for the Homeless Council
  • SAMHSA-HRSA Center for Integrated Health Solutions
  • Opening Doors, Federal Strategic Plan to Prevent and End Homelessness
  • Corporation for Supportive Housing
  • Technical Assistance Collaborative
  • Contact: