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

Low Income Housing Policy

Income Support/ Disability Policy

Mental Health/Social Service Policy Bureaucracies: Deliver Policy Benefits to the Citizen Level

Public Housing Authority SSA/VA Disability City Welfare Mental Health Agency SH Case Manager/Broker Relationship Rent Subsidy/ Entitlement- Quality Standards Cash Payment/ Entitlement/Payee Supported Employment

Regime of Redistribution of Wealth: “The SYSTEM”

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)

MONEY FROM EMPLOYMENT LAST 30 DAYS

$104 24.1%

MONEY FROM WELFARE LAST 30 DAYS

$57 13.1%

UNEMPLOYMENT INSURANCE LAST 30 DAYS

$7 1.7%

VALUE OF FOOD STAMPS LAST 30 DAYS

$37 8.5%

PENSION/DISABILITY LAST 30 DAYS

$144 33.2%

MONEY FROM MATE,FAMILY,FRIENDS-30 DAYS

$5 1.1%

OTHER SOURCES MONEY LAST 30 DAYS

$80 18.4%

Total income

$433

100.0%

Disability/Welfare

$201

46.3%

Mean Percent

Monthly Income in 2014 dollars

Monthly Income in 2014 Dollars (Sources and % of Total)

CATIE % of All RAISE 2 Yrs % of All Chronic Schizophrenia Income First Episode Schizophrenia 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% Total

$1,035 100.00% $741 100.00%

Total Disability

$716 69.23% $314 42.40%

Non disability Public Support

$73 7.06% $129 17.42%

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 20 40 60 80 100

Baseline 6 mos. 1 year 18 mos. 2 years 3 years

% days housed in past 60

VASH exp. : N=182 Case mgt. N=88

• Std. care: N=187

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

10 20 30 40 50 Baseline 6 mos. 1 year 18 mos. 2 years 3 years

% days homeless in past 60 VASH exp. : N=182 Case mgt. N=88

• Std. care: N=187

Outcomes in the HUD-VA Supported Housing Program: Psychological Distress (BSI global severity index)

0.25 0.5 0.75 1 1.25 1.5

Baseline 6 mos. 1 year 18 mos. 2 years 3 years

VASH exp. : N=182 Case mgt. N=88

• Std. care: N=187

Outcomes in the HUD-VA Supported Housing Program: Days of Alcohol Use in past 30 days 2.5 5 7.5 10

Baseline 6 mos. 1 year 18 mos. 2 years 3 years

Days of alocohol use

VASH exp. : N=182 Case mgt. N=88

• Std. care: N=187

Graph of Social Integration Factors Over Time: Collaborative Initiative on Chronic Homelessness

• 1.4
• 1.2
• 1
• 0.8
• 0.6
• 0.4
• 0.2

0.2 0.4 0.6 0.8 Baseline 6 months 12 months Factor scores Factor 1: Housing Factor 2: Community Participation Factor 3: Civic Activities Factor 4: Religious Faith Factor 5: Social Support Factor 6: Mental Health Support

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

• No days of alcohol or

drug use in last 30 when first housed

N=290

High Frequency (HF) Users

• >15 days of alcohol or

drug use in last 30 when first housed.

N=120

Days Housed in Past 90 (following first interview when housed)

10 20 30 40 50 60 70 80 90 100 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.

$47,116 $40,916

$0 $10,000 $20,000 $30,000 $40,000 $50,000 $60,000

Societal Costs

Costs

• 1. Experimental VASH (N=182)
• 2. CM controls (N=90)
• 3. Standard care (N=188)

`

Three-year VA outpatient costs by treatment group.

$10,183 $5,539 $1,544$1,784 $3,741 $7,253 $634 $1,522 $7,729

$0 $3,000 $6,000 $9,000 $12,000

Psychiatric and Substance Abuse Tx. OP Med-Surg Homeless Case Management

VA Costs

• 1. Experimental VASH (N=182)
• 2. CM controls (N=90)
• 3. Standard care (N=188)

VA inpatient and residential treatment costs one year before and three years after randomization, by 6-month interval (1).

$0 $2,500 $5,000 $7,500 $10,000 $12,500 $15,000

12-6 6-0 0-6 6-12 12-18 18-24 24-30 30-36

VA Cost/6 month interval

• 1. Experimental VASH

(N=182)

• 2. CM controls (N=90)
• 3. Standard care (N=188)

Randomization (1) All comparisons were non- significant at p<.05 (ANOVA).

Three-year non-health expenditure by treatment group.

$1,347 $4,784 $2,375 $867 $453 $2,017 $3,316 $5,074 $393 $4,774 $1,629 $5,935

$0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000

Total non-health expend. Homeless Shelter Incarceration Admin Cost of Transfers

Non-health expenditure

• 1. Experimental VASH (N=182)
• 2. CM controls (N=90)
• 3. Standard care (N=188)

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

Rosenheck and Mares, 2007

44

Days Worked Regular Jo Job (P (Past 30)

2 4 6 8 10 12 b l 3

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Days Housed in past 90 (Independent)

(Least Square Means)

5 10 15 20 25 30 35 40 45 bl 3- mo 6- mo 9- mo 12- mo 15- mo 18- mo 21- mo 24- mo Supported Employment Control 38% independently housed 33% independently housed

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

• f 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).

No evidence that Supported Housing Im Improves For r Health Housing, Health, and Homelessness: Evaluating the Evidence (National Academy of Science, 2019)

• …the committee finds that there is no substantial

published evidence as yet to demonstrate that PSH [Permanent Supported Housing] improves health

• utcomes or reduces health care costs.
• Remaining housed should improve the health of these

individuals because housing alleviates a number of negative conditions that detract from their ability to achieve “a state of complete physical, mental and social well-being”

Years of Potentia ial Lif ife Lost before the Age of 75 per Person-Year

• f Observation in

in the Homeless Cohort and the 1987 General Population of Phila iladelphia (NEJM, , 1994)

Mortality among Homeless and Non-homeless Mentally Ill Veterans

Survival functions for age and homelessness groups. NH = not homeless (triangles); SD = short-duration homeless (circles); LD = long-duration homeless (squares). Age 35 to 44 (dotted lines); age 45 to 54 (dashed lines); age 55 and over (solid lines).

Mortality in Housing First(Henwood, 2014)

Mortality In Housing First (Henwood, 2014)

Housing First Others

Conclusions

• Supported Housing does move individuals out of

Homelessness

• Requires a System of Redistribution: From politics and policy

to case management

• Little evidence of improvement in physical health or

mortality

• Increases costs: Is it worth it?
• Is it a solution to the homeless problem?

What do we value? For whom?

• Should all Americans be housed ? (i.e.

a right?)

• Moral choices: Equality vs. Freedom
• What would we sacrifice for this goal?
• Could a war on homelessness be won?
• Why has it never been asked?