of Aged Homelessness: Could Housing Solutions Be Funded by - - PowerPoint PPT Presentation

The Emerging Crisis

• f Aged Homelessness:

Could Housing Solutions Be Funded by Avoidance of Excess Shelter, Hospital, and Nursing Home Costs?

Dennis Culhane, PhD, Dan Treglia, PhD Thomas Byrne, PhD Stephen Metraux, PhD Randall Kuhn, PhD Kelly Doran, MD MHS Eileen Johns MPA, Maryanne Schretzman, DSW

Funders

New York State Health Foundation Conrad N. Hilton Foundation Aileen Getty Foundation Blue Cross Blue Shield of Massachusetts Foundation

Data Providers NYC Department of Social Services NYS Department of Health Center for Medicare and Medicaid Services, Mission Analytics Los Angeles Homeless Services Authority County of Los Angeles California Office of Statewide Health Planning and Development MassHealth Boston Department of Neighborhood Development

Acknowledgements

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Projections of the Aging Homeless Population Understanding Healthcare Service Usage of Older Homeless Adults Identifying Subgroups by Shelter & Healthcare Service Use Identifying Potential Cost Offsets Considering Stakeholders & Possible Next Steps

Agenda for Presentation

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Homelessness, A Birth Cohort Phenomenon

6 4 2 8 10 12

% of Single Adult Male Homeless Population

Single Adult Male Shelter Users, United States Sheltered Homeless Single Adult Males Aged 46-54 % 1990 1 in 8 in 1990 2000 1 in 5 in 2000 2010 1 in 3 in 2010

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Forecasting Change in 65+ Homeless Population

1.0 1.5 2.0 2.5 3.0

Population Growth Relative to 2017

Los Angeles Boston

2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

New York City

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NYC Age 50+ Shelter population forecast

5,000 10,000 15,000 20,000 25,000 2004 2006 2008 2010 2012 2014 2020 2022 2024 2026 2028 2030 50-54 55-59 60-64 65-69 70+ 2016 2017 2018

Actual

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Forecast

7,000 6,000 5,000 4,000 3000 2,000 1,000 8,000

65-69 70-74 75-79 80+

NYC Age 65+ Shelter population forecast

2004 2006 2008 2010 2012 2014 2020 2022 2024 2026 2030 2028 2016 2017 2018

Actual

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Forecast

Change in Shelter Population for 5-Year Birth Cohorts: New York City, 2005 - 2030

6,000 5,000 4,000 3,000 2,000 1,000 1945-49

1960-64 Number of adults in Shelter

1950-54 1955-59 2005 2010 2015 2020 2025 2030

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Aging Homelessness Trends Across U.S

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Boston Shelter: City of Boston HMIS Health care: MassHealth Medicaid Claims Homeless Services Authority & Los Angeles Shelter: Los Angeles Point-in-Time Count Health care: LA Enterprise Linkage Project (Departments of Public Health, Mental Health, & Health Services), CMS (through Mission Analytics); California Office of Statewide Healthcare Planning & Development New York City Shelter: NYC Department of Social Services Health care: NYS Department of Health SPARCS Database, CMS (through Mission Analytics)

Examining Shelter, Healthcare, and Nursing Home Use & Costs of Older Homeless Adults Data Sources

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Average Annual Per Person Costs by Age: New York City

$25,159 $24,455 $27,314 $28,457 $5,000 $0 $10,000 $15,000 $20,000 $25,000 $30,000 55-59 60-64 65-69 70+

Nursing Home Inpatient Care ED Visit Shelter

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Nursing Home Use by Age: LA County

8 6 4 2

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20 18 16 14 12 10

# of Days in Nursing Homes

31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 Age

Projecting Total Costs through 2030: New York City

Costs Per Y ear, millions of $ $500 $450 $400 $350 $300 $250 $200 $150 $100 $50 $0

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

Shelter Healthcare

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Cluster Analysis: A tool for grouping observations based on similarities and dissimilarities Clusters were created based on a small set of variables, and validity was assessed through other variables of service use and medical acuity

Segmenting into Subgroups to Assess Potential Housing & Service Needs

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Shelter Use

Low Moderate Very High Low Moderate High High

Shelter Days 2009 - 2015 Gagne Inpatient Comorbidity Hospital Days Index 2011 - 2015 Cluster Description 1 Moderate shelter use, Moderate medical need 11,354 (84.6%) 270 2.2 16 2 High shelter use, Moderate medical need 1,536 (11.4%) 1,191 3.1 20 3 Very high shelter use, Moderate medical need 193 (1.4%) 2,201 1.9 14 4 Low shelter use, High medical need 344 (2.6%) 56 32.5 253 Cluster Share

Subgroup Analysis Results

Medical Need

Cluster 4 2.6% Cluster 1 84.6% Cluster 2 11.4% Cluster 3 1.4% 15

Shelter Days Inpatient Days ED Visits Nursing Home Days Shelter Cost Health Services Cost Total Services Cost

Cluster 1 44 3 1 9 $5,167 $13,369 $18,536 Cluster 2 196 4 2 6 $23,018 $15,870 $38,888 Cluster 3 329 3 1 3 $38,638 $10,281 $48,919 Cluster 4 9 51 10 32 $1,075 $175,437 $176,494

4 1 2 3

Shelter Use Medical Need

Subgroups: Annualized Shelter & Healthcare Use

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Envisioning a Continuum of Potential Interventions

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Expect homelessness to self-resolve for one-third of this cluster, as people move in with friends, family, partners, etc. For the remaining 2/3, we assume an equal division of: Rapid Rehousing: relocation and case management services and time-limited rental assistance Shallow rental subsidies: for those needing ongoing modest rental assistance for shared living arrangements and minimal financial and social service support Rental vouchers, like those available through HUD’s Section 202 program, in addition to light case management, and likely to be living alone

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Subgroup 1: Progressive Engagement

4 1 2 3

Shelter Use Medical Need

Long-term housing + supportive services for chronically homeless populations All three groups may need advanced case management and home care services that allow for aging in place Subgroup 4 are likely candidates for palliative care and additional nursing home transition services

Subgroups 2, 3, and 4: Permanent Supportive Housing

4 1 2 3

Shelter Use 19 Medical Need

Estimating Costs for Each Intervention

Intervention Annual Housing Cost Annual Service Cost Total Annual Cost Cluster 1 Subsidy + Services $4,795 $1,650 $6,444 Cluster 2 PSH $15,468 $11,500 $26,968 Cluster 3 PSH $15,468 $11,500 $26,968 Cluster 4 PSH + Additional Supports $15,468 $23,000 $38,468

4 1 2 3

Shelter Use Medical Need

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Estimating Service Cost Reductions

1.Aubry T, Goering P, Veldhuizen S, et al. A Multiple-City RCT of Housing First With Assertive Community Treatment for Homeless Cana- dians With Serious Mental Illness. Psychiatr Serv. 2016;67(3):275-281. 2.Basu A, Kee R, Buchanan D, Sadowski LS. Comparative cost analysis of housing and case management program for chronically ill homeless adults compared to usual care. Health Serv Res. 2012;47(1 Pt 2):523-543. 3.Rosenheck R, Kasprow W, Frisman L, et al. Cost-effectiveness of Supported Housing for Homeless Persons With Mental Illness. Arch Gen Psychiatry. 2003;60(9):940. 4.Stergiopoulos V, Hwang SW, Gozdzik A, et al. Effect of scattered-site housing using rent supplements and intensive casemanagement

• n housing stability among homeless adults with mental illness: a randomized trial. JAMA. 2015;313(9):905-915.

5.Byrne T, Smart G. Estimating Cost Reductions Associated with the Community Support Program for People Experiencing Chronic

• Homelessness. Boston, MA; 2017.

6.Culhane DP, Metraux S, Hadley T. Public Service Reductions Associated with Placement of Homeless Persons with Severe Mental Illness in Supportive Housing. Hous Policy Debate. 2002;13(1):107-163.

• 7. Gilmer T, Manning W, Ettner S. A Cost Analysis of San Diego County’s REACH Program for Homeless Persons. Psychiatr Serv. 2009.

8.Larimer ME, Malone DK, Garner MD, et al. Health care and public service use and costs before and after provision of housing for chron- ically homeless persons with severe alcohol problems. JAMA. 2009;301(13):1349-1357. 9.Martinez TE, Burt MR. Impact of permanent supportive housing on the use of acute care health services by homeless adults.Psychiatr

• Serv. 2006;57(7):992-999.

10.Seligson A, Levanon S, Lim T, et al. New York/New York III Supportive Housing Evaluation: Interm Utilization and Cost Analysis. New York; 2013. 11.Srebnik D, Connor T, Sylla L. A pilot study of the impact of housing first-supported housing for intensive users of medical hospitaliza- tion and sobering services. Am J Public Health. 2013;103(2):316-321. 12.Hunter SB, Harvey M, Briscombe B, Cefalu M. Evaluation of Housing for Health Permanent Supportive Housing Program. Santa Monica, CA; 2017. 13.Mares AS, Rosenheck RA. Twelve-Month Client Outcomes and Service Use in a Multisite Project for Chronically Homelessness Adults. 14.Thomas LM, Shears JK, Pate MC, Priester MA. Moore Place Permanent Supportive Housing Evaluation Study Final Report. Char- lotte, NC

• 15. Wright BJ, Vartanian KB, Li H-F, Royal N, Matson JK. Formerly Homeless People Had Lower Overall Health Care Expenditures After

Moving Into Supportive Housing. Health Aff. 2016;35(1):20-27.

Service Cost Reduction Scenarios

Scenario 1

More conservative Based on a pooled average of the percentage change in health care costs associated with housing placement that were observed in all studies that were reviewed. Studies were weighted so those with stronger methodological rigor had larger weights and greater impact

• n the pooled average.

Scenario 2

Less conservative Based on a pooled average of the percentage change in health care costs associated with housing placement that were observed in all studies that identified a significant reduction in health care costs.

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A Range of Potential Service Cost Reductions

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Cost Category Scenario 1 (More conservative) Scenario 2 (Less conservative) Inpatient medical

• 18%
• 33%

Emergency Department

• 6%
• 45%

Outpatient medical

• 6%
• 45%

Outpatient behavioral health

48%

• 29%

Inpatient behavioral health

• 35%
• 56%

Nursing home

• 42%
• 90%

Shelter

• 71%
• 71%

Cost Reduction Possibilities by Age Group: LA County Average per Person Per Year

$5,498 $8,869 $5,951 $9,834 $6,570 $10,668 $6,978 $6,969 $11,346 $4,000 $2,000 $- $6,000 $8,000 $10,000 $12,000

t

Age 55-59 Age 60-64 Age 65-69 Age 70+ More Conservative Less Conservative

Cost Reduction Scenarios Housing Intervention Cos

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Cost Reduction Possibilities in NYC Average Per Person Per Year

$9,171 $13,215 $11,033 $0 $8,000 $6,000 $4,000 $2,000 $10,000 $12,000 $14,000 More Conservative Less Conservative Service Cost Reductions Housing Intervention Cost

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Cost Reduction Possibilities in Boston Average Per Person Per Year

$4,946 $9,073 $9,052 $10,000 $9,000 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 More Conservative Less Conservative

Service Cost Reductions Housing Intervention Cost

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* Boston service costs and cost reductions exclude Medicare-reimbursed services. A forthcoming analysis estimating Medicare costs suggests that an intervention would be break-even or provide net savings

Annualized Average Projected Costs & Potential Cost Reductions (in millions of $)

Net Offsets (Service Cost Service Costs without an Intervention Interventio n Costs Average Service Cost Reductions Reductions - Intervention Costs) Return Per Dollar Spent New York City $408 $157 $177 $20 1.13 Boston* $67 $39 $30 ($9) 0.77 LA County $621 $241 $274 $33 1.14

Yes Could Housing Solutions be Funded by Resultant Service Cost Reductions?

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National Projections (with cautions)

250,000 200,000 150,000 100,000 50,000 2017 2018 2019 2020 2021 2022 2025 2026 2027 2028 2029 2030 2023 2024 55-64 65+

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U.S. HUD & V A U.S. DHHS – CMS State Medicaid Regulatory Agencies Medicaid Managed Care Organizations Hospitals & nursing homes Homeless Service Providers (CoC’s) Housing Authorities Local Area Agencies on Aging

Key Stakeholders

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• How to advance fund the housing “investment”?
• MCOs as rapid rehousing funder under a critical time

intervention model?

• Start now targeting hospital and ER discharges and nursing

home diversion?

• Ramp up over time, starting with 65+ or 62+ to gain

momentum and develop policies and procedures?

• Federal challenge grant program to states for pilots?
• Local/state pay for shallow subsidies as alternative to

shelter, and sunsetting over time?

• Hospitals as key local leaders and conveners? Dissuade from

“medical respite” push?

Policy Considerations

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