Does it Save Lives? What does it have to do with mental illness? - PowerPoint PPT Presentation

What is Supported Housing? Does it Save Lives? What does it have to do with mental illness? Robert Rosenheck MD Yale Medical School October 21, 2019

Starting With A Housing Perspective

Urban Renewal

Growth of Suburbia

1980s: Gentrification and the “New Homeless”

Where “The rubber hits the road”

Central Dogma Income + Low Rents + Rent Subsidies = Housed People

Regime of Redistribution of Wealth: “The SYSTEM” Mental Health/Social Low Income Income Support/ Service Policy Disability Policy Housing Policy Bureaucracies: Deliver Policy Benefits to the Citizen Level Mental Health SSA/VA Disability Public Housing Agency City Welfare Authority Employment Supported Rent Subsidy/ SH Case Cash Payment/ Entitlement- Quality Manager/Broker Entitlement/Payee Standards Relationship

Regime of f Redistribution of Wealth: Federal Housing Expenditures: 2017 • Mortgage Interest Deduction resulted in a loss of 2017 federal tax revenues of over: $66.0 billion • 84% to households with income > $100,000. • Housing subsidies (tenant based rental assistance, public housing, project base assistance, homeless assistance): $39.5 billion • Why the difference? • Entitlement (no limit) vs budget (limited availability)

Income: Homeless Veterans in HUD-VASH (HUD-VA Supported Housing) Mean Percent MONEY FROM EMPLOYMENT $104 24.1% LAST 30 DAYS MONEY FROM WELFARE LAST $57 13.1% 30 DAYS UNEMPLOYMENT INSURANCE $7 1.7% LAST 30 DAYS VALUE OF FOOD STAMPS LAST $37 8.5% 30 DAYS PENSION/DISABILITY LAST 30 $144 33.2% DAYS MONEY FROM $5 1.1% MATE,FAMILY,FRIENDS-30 DAYS OTHER SOURCES MONEY $80 18.4% LAST 30 DAYS $433 Total income 100.0% $201 Disability/Welfare 46.3%

Monthly Income in 2014 dollars Monthly Income in 2014 Dollars (Sources and % of Total) CATIE % of All RAISE 2 Yrs % of All Chronic First Episode Schizophrenia Schizophrenia Income Income Earned Income $188 18.18% $298 40.19% Voc Rehab program income $8 0.81% $0 0.00% SS Ret $22 2.14% $0 0.00% SSD $322 31.08% $165 22.28% SSI $227 21.98% $149 20.11% VA Disability $139 13.39% $0 0.00% VA Pension $29 2.79% $0 0.00% Other Welfare $11 1.02% $19 2.52% Unemployment Insurance $6 0.56% $0 0.00% Retirement/Investment $21 2.02% $0 0.00% Rent Subsidy $41 3.98% $43 5.80% Food stamps $21 2.06% $67 9.09% $1,035 100.00% $741 100.00% Total $716 69.23% $314 42.40% Total Disability $73 7.06% $129 17.42% Non disability Public Support

SSI Minimum Wage Poverty Income Average renter income

What to do?

Homeless Services Without Housing

What’s in a name? Supported Housing Supportive Housing Housing First (championed by Sam Tsemberis PhD)

Supported Housing Basics • What is it? • What do you do? • What benefits • What cost?

Experimental Study: Housing Urban Development-Veterans Affairs Supported Housing (HUD-VASH): 1. HUD-VASH (Voucher + Case Management) 2. Case Management-No Voucher 3. Standard HCHV Treatment

Case Management (CM) by the Numbers: First Three Months CM+Voucher CM Alone Control Voucher by 3 Mos. 55% 2% 1% Helped Locate Apt. 44% 26% 9% Apts. CM Visited 2.1 0.6 0.0 CM met Landlord 71% 45% 0% Helped Furnish Apt. 37% 22% 4% Vet .Terminated 8% 17% 53% Therap Alliance (Vet.) 4.7* 4.4 4.3

Case Management (CM) Services Longer-term Involvement CM+Voucher CM Alone Control Duration of partic. (yrs) 3.4 2.7 0.8 Time in community (yrs) 3.2 2.5 0.6 Participated>2 years 64% 50% 11%

Outcomes in the HUD-VA Supported Housing Program: Percentage of Days Housed in Past 60 days 100 % days housed in past 60 80 60 40 VASH exp. : N=182 Case mgt. N=88 Std. care: N=187 20 0 Baseline 6 mos. 1 year 18 mos. 2 years 3 years

At Homes/Chez Soi: Canadian National Experimental Study of Housing First

Outcomes in the HUD-VA Supported Housing Program: Percentage of Days Homeless in Past 60 days 50 % days homeless in past 60 40 VASH exp. : N=182 Case mgt. N=88 Std. care: N=187 30 20 10 0 Baseline 6 mos. 1 year 18 mos. 2 years 3 years

Outcomes in the HUD-VA Supported Housing Program: Psychological Distress (BSI global severity index) 1.5 1.25 1 VASH exp. : N=182 0.75 Case mgt. N=88 0.5 Std. care: N=187 0.25 0 Baseline 6 mos. 1 year 18 mos. 2 years 3 years

Outcomes in the HUD-VA Supported Housing Program: Days of Alcohol Use in past 30 days 10 VASH exp. : N=182 Case mgt. N=88 7.5 Days of alocohol use Std. care: N=187 5 2.5 0 Baseline 6 mos. 1 year 18 mos. 2 years 3 years

Graph of Social Integration Factors Over Time: Collaborative Initiative on Chronic Homelessness 0.8 0.6 0.4 0.2 Factor 1: Housing 0 Factor 2: Community Participation Factor scores -0.2 Factor 3: Civic Activities -0.4 Factor 4: Religious Faith Factor 5: Social Support -0.6 Factor 6: Mental Health Support -0.8 -1 -1.2 -1.4 Baseline 6 months 12 months

At Home/Chez Soi: Functioning (p<.01)/Quality of Life)(p<.01)(esp. first year)

Harm reduction: Allowing substance use Substance use status when FIRST HOUSED Abstainers High Frequency (HF) Users • No days of alcohol or • >15 days of alcohol or drug use in last 30 when drug use in last 30 when first housed first housed. N=290 N=120

Days Housed in Past 90 (following first interview when housed) 100 90 80 70 60 50 40 30 20 10 0 BL 3M 6M 9M 12M 15M 18M 21M 24M ABSTAINERS ACTIVE SUBSTANCE USERS (>15 days/month)

PAST 30-DAY SUBSTANCE USE: LS MEANS DAYS INTOXICATED: 2 YEAR OUTCOMES

PAST 90-DAY SYMPTOM SCORES (BSI): 2 YEAR OUTCOMES

Three-year costs by treatment group. $60,000 1. Experimental VASH (N=182) 2. CM controls (N=90) 3. Standard care (N=188) $50,000 $47,116 $40,916 $40,000 Costs $30,000 ` $20,000 $10,000 $0 Societal Costs

Three-year VA outpatient costs by treatment group. $12,000 $10,183 $9,000 $7,253 1. Experimental VASH (N=182) VA Costs $7,729 2. CM controls (N=90) 3. Standard care (N=188) $5,539 $6,000 $3,741 $3,000 $1,544$1,784 $1,522 $634 $0 Psychiatric and OP Med-Surg Homeless Case Substance Abuse Tx. Management

VA inpatient and residential treatment costs one year before and three years after randomization, by 6-month interval (1). $15,000 Randomization VA Cost/6 month interval $12,500 1. Experimental VASH $10,000 (N=182) 2. CM controls (N=90) $7,500 3. Standard care (N=188) $5,000 $2,500 (1) All comparisons were non- significant at $0 p<.05 (ANOVA). 12-6 6-0 0-6 6-12 12-18 18-24 24-30 30-36

Three-year non-health expenditure by treatment group. $5,935 $6,000 $5,074 Non-health expenditure $4,784 $4,774 $5,000 1. Experimental VASH (N=182) 2. CM controls (N=90) $4,000 3. Standard care (N=188) $3,316 $3,000 $2,375 $2,017 $2,000 $1,629 $1,347 $867 $453 $1,000 $393 $0 Total non-health Homeless Incarceration Admin Cost of expend. Shelter Transfers

At Home/Chez Soi Costs: ACT vs Intensive Case Management

Incremental CE Ratio HUD-VASH TRIAL: Three-year incremental cost per day housed ICER 95% CI • VA health care $58 $4 to $111 • Health System $50 -$17 to $117 • Society $45 -$19 to $108 • Government $74 $ 5 to $143

Does Supported Housing Impact Homelessness Among Homeless Populations

HUD Point in Time Count of Homeless Adults

What about employment? Individual Placement, and Support Model • Non-Equivalent Cohort Design • Two phases • Phase 1 (N = 309) • Prior to hiring employment specialists • Veterans in HCHV program offered TWE • Followed for two years • Phase 2 (N = 322) • 9 sites • Veterans in HCHV program offered IPS (SE) • Followed for two years 44 Rosenheck and Mares, 2007

Days Worked Regular Jo Job (P (Past 30) file://localhost/.file/id=65713 67.2992255 12 10 8 teps 6 control 4 2 0 l * * * b * * * * * * * * * * * o * * o * * o o o m o o o m m m m m m m - 8 - - - - - 6 - 2 5 1 1 - 3 9 4 1 1 2 2 45

Days Housed in past 90 (Independent) (Least Square Means) 38% independently 45 housed 40 35 30 Supported 33% independently 25 Employment housed 20 Control 15 10 5 0 bl 3- 6- 9- 12- 15- 18- 21- 24- mo mo mo mo mo mo mo mo

The Physical Health Connection: Saving Lives • Medicalization from the beginning: 1980s • Reaction against the Great Society • Housing, Health, and Homelessness: Evaluating the Evidence (National Academy of Science, 2019)

Homelessness People Have Poor Health: Cause or r Effect? • The IOM’s 1988 finding that the lack of stable housing has a direct and deleterious impact on health (IOM, 1988); • WHO’s broad notion of health, and the role of housing as an influencer of health (WHO, 1994); and • The National Academies report findings reiterating that housing is a social determinant of health (NASEM, 2016, 2017).