From Safety Net to Trampoline: On-the-ground strategies for becoming a housing crisis response system Katharine Gale Using the Right Tools to End Homelessness Hartford, CT March 20, 2012 kgaleconsulting@sbcglobal.net 1
Overview • Moving toward a system of crisis resolution: shifting the paradigm • How should we invest our resources? • How do we review program performance? • What makes us work as a system? – Coordinating our efforts from first touch to exit – Targeting our resources • Prevention • Higher Cost Interventions – What does this mean for our work? 2
The Past Prev/ Out- RRH Shelter reach TH Other PSH Objectives: • Maximize and keep funding in Continuum • Keep programs open and operating • Collaborate to increase resources • Maintain high standards for serving people • Focus on a variety of individual client results 3
Each program a separate net that catches some people 4
Housing Crisis Resolution System Objectives: • Permanent housing fast and make sure housing sticks • Least expensive resource to each household to resolve their homelessness • Measure what is working, do right amount of that • Measure what is not working, do better and/or less of that 5
Stretching the nets together…. 6
Does the current set of components fit the need? 7
Local data sources • Information from Homeless Management Information System (HMIS) (destinations, lengths of stay) • Information from local HUD-mandated reports (APR, AHAR, HIC) • Program-level information (budgets, number of beds, persons served) • Homeless point-in-time count 8
Population Distribution & System Capacity – Community B 9
Population Distribution & System Capacity – Community B 10
Engineering Success Each System Component: • Leads to success – exits to permanent housing (PH) • Right-sized allocation of system dollars to maximize PH exits 11
Success: Exits to PH Percent of Initial Exits to Permanent Housing – Community A Persons in HH with Children, 2010 100% 90% 89% 80% 70% 71% 60% 50% 40% 30% 30% 20% 10% 0% Shelters TH RR 12
Success: Exits to PH 13
Success that Sticks Success that sticks means leaving homelessness for permanent housing & not returning to homelessness . 14
Returns to Homelessness 15
Returns to Homelessness 16
Sources: HMIS & HPRP data collection tool, 2010 program stays, 2011 returns data. Budget data from provider agencies, in a few cases estimates created from publicly available information. 17
Sources: HMIS & HPRP data collection tool, 2010 program stays, 2011 returns data. Budget data from provider agencies, in a few cases estimates created from publicly available information.
Maximizing Success Lowest cost of Success that Sticks Greatest Number Housed Maximum Resources 19
Where are resources invested now? 20
Where are resources invested now? 21
What would happen, if…? Program LOS Program LOS Shorten LOS TH 300 days TH 150 days 302 new PH Exits! 22
What would happen, if…? Program Current $ Program New $ Swap TH $6,415,004 TH $4,415,004 $2 mil RR $2,052,760 RR $4,052,760 592 net new PH exits! 23
Maximizing Success that Sticks Includes: • Right-sizing investments by program type according to cost and outcomes, and • Assessing program performance and making funding decisions accordingly 24
System performance is the sum of the parts 25
Rewarding Performance • Moving toward outcomes-based contracting • Make expectations clear • Flexibility/Simplify reporting • Offer recognition/incentives • Provide training, bring players along 26
Making the System Work: Greasing the Wheels • Coordinated entry • Assessment & assignment of right resource • Buy-in to common outcomes • Measuring outcomes & responding to findings 27
Coordinated Entry Stabilize current Assess needs housing and barriers Point of Refer to shelter Entry and/or re- housing Immediate re-housing Direct to PSH in some cases Slide from National Alliance to End Homelessness: System Design Webinar October 2010
Coordinated Entry Why is it important? -Fairness to clients - Better use of resources - Improves targeting - Accountability: Means someone “has the ball” - Supports a system paradigm and helps providers do their job …Not a panacea - will show gaps in system 29
Targeting • Applying resources where they are most needed based on our best understanding of the data – Ask: can we keep them from coming in? – If they come in, how fast can we get them out? – Save our highest cost interventions for those who really need them as demonstrated by past utilization in our system or other systems 30
Prevention Targeting: Comparative Entry Analysis 80% 74% Singles in Shelters 70% Singles in HPRP 60% With Family 50% and Friends 36% 40% 30% 18% 17% 16% 20% 15% 9% 10% 4% 4% 2% 2% 2% 1% 1% 0% 0% 0% 0% 0% Already in System Unsubsidized Hotel/Motel Other Refused Housing Subsidized With Family Don’t Know Institution Housing and Friends 31
Other data on sheltered households in HMIS • Income amounts • Typical Income Sources • Prior Shelter stays • Age of Head of Household • Pregnancy/Age of Children • Education Level Hennepin County did this and redid their prevention screening tool. 32
From 2012 Homebase Study (Shinn and Greer… publishing soon) High Risk of Shelter Entry (Risk Factor): • Female Head of Household • Pregnancy • Child younger than two • History of public assistance • Eviction threat • High mobility in last year • History of protective services • High conflict in household • Disruptions as a child (e.g. foster care, shelter history as youth) • Shelter history as an adult • Recent shelter application • Seeking to reintegrate into community from an institution • High number of shelter applications 33
Prevention Goal: Make a difference in subsequent rates of entry 34
Targeting Higher Cost Interventions • Even programs for most high need can be developed and run with the idea of the trampoline… (a slow trampoline) – CTI model – Frequent User Programs • Finding the users of ours or other systems 35
Program Use & Implications – Community B 36
Program Use & Implications – Community B 37
Projects Serving Frequent Users of Emergency Services • New Directions – Santa Clara County, Hospital Council of Northern and Central California • SF Emergency Department Case Management – San Francisco General Hospital • Project RESPECT – Berkeley/Oakland, LifeLong Medical Care
Populations Served Similarities Across Programs • Adults ages 18 and older • 75 - 85% males • Homeless • Uninsured • High prevalence of mental health/substance use issues • Hospital data identifies frequent and avoidable ED visits
Common Service Components • Assertive Outreach • Case Management / Brokerage services • Crisis Intervention • Medical Assessment and Care • Psychiatric Assessment and Care
LifeLong Medical Care Project RESPECT • FQHC in Berkeley, Oakland and Richmond (9 primary care clinics, 1 dental clinic, large supportive housing program) • Frequent User program since 2005 • Contracts to serve 3 hospitals (Highland, Alta Bates, Summit) • Served 250 frequent users
Project RESPECT Model • Core service team – case managers and LCSW provide outreach and services • Based in a primary care setting; also does benefits advocacy • 10 or more visits per year to the ED or 4 visits/yr. for 2 consecutive years • Contracted to serve total of 80 clients at any point in time, case load 1:20. • Connected to housing resources (Shelter Plus Care)
Impacts and Outcomes • Program costs average $5,000 to $5,500 a year (not including housing) • Average program stay is under one year • 88% of clients without an income approved for SSI • Clients decrease ED visits by 63% • Increase in inpatient visits in first year (chronic illnesses, deferred care) which decreases in year two • Hospitals supporting because reduces ED stress and increases ability to bill once client has Medicaid 43
Key element: Hospital Coordination • Identifying key staff who have buy in • Flags in hospital systems to identify project clients • Patient coordination, reinforcement of messages • Access to real time ED and inpatient data • Pain management support/coordination • Strengthen referrals back to the primary care source
Information Exchange • Identify target population • Provide feedback to staff on what has happened to referred patients • Track outcomes • Track cost • Provide positive reinforcement for referrals (case studies and data) • HIPAA issues
Things we have to stop saying/believing… • “There is no housing…” • “There are no services…” • “We are setting them up for failure…” • “We need a lot more resources to improve performance…” 46
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