1. Targeting Supportive Housing to High-Cost/ Frequent Users of Public Systems Richard Cho NAEH 2011 Conference July 13, 2011

2. 2 Corporation for Supportive Housing CSH is a national non-profit organization that helps communities create permanent housing with services to prevent and end homelessness. CSH advances its mission through advocacy, expertise, innovation, lending, and grantmaking.

4. He suffers from schizophrenia, depression, and drug addiction

5. Has had inconsistent mental health care and multiple encounters with drug treatment programs

6. He has spent most of the last 12 years on a revolving door between streets, shelter, hospitals, and jail

7. He is wary of new people and mistrustful of service providers, and is often viewed as anti-social3

8. 4

9. 5 Jail Detox Emergency Residential Program Shelter Psychiatric Hospital Emergency Room The Institutional Circuit of Homelessness and Crisis Service Systems The “institutional circuit”: Indicates complex, co-occurring social, health and behavioral health problems Reflects failure of mainstream systems of care to adequately address needs Demands more comprehensive intervention encompassing housing, intensive case management, and access to responsive health care

10. 6 High Use of Public Services with Poor Outcomes In many communities, there exists a subset of individuals who consume a disproportionate amount of health services with no improvements to health outcomes Billings’ (2006) analysis of NYC Medicaid claims data found that: 20% of adult disabled patients subject to mandatory managed care account for 73% of costs 3% of patients accounting for 30% of all costs for adult disabled patients

11. Why Target SH to High Cost / Frequent Users? Moral Argument: “They have complex needs that are slipping through the cracks of service systems and should be prioritized for help.” Economic/Efficiency Argument: “Targeting high-cost and frequent users can result in cost offsets to the public.” The Governance/Reform Argument: “The institutional circuit shows that our public systems are broken. We need to break down silos and shift public spending towards proven solutions that work.” 7

12. “Touching the Elephant in the Dark” Government functions in specialized departments/agencies that each view problems in specialized ways Multi-dimensional problems are therefore viewed in a fractured way Each agency has only a piece of the larger story 8

13. “When holding a hammer, everything looks like a nail” Each government agency uses what limited tools and instruments it has at its disposal to try to fix problem, even when it know it is inadequate Solutions become piecemeal, focused on only a part of the problem and therefore, ineffective 9

14. The Creeping Institution As solutions chase problems, an unintended consequence is the gradual expansion of the institution, at great costs and poor outcomes 10 Client Institution

15. The Solution: CSH’s Frequent User Systems Engagement (FUSE) Initiative

16. FUSE Premise Thousands of people with chronic health conditions cycle in and out of crisis systems of care and homelessness - at great public expense and with limited positive human outcomes. Placing these people in supportive housing will improve life outcomes for the tenants, more efficiently utilize public resources, and likely create cost avoidance in crisis systems like jails, hospitals and shelter. 12

17. Pillars and Steps of FUSE 13

18. Cross-System Data Match Provides Recruitment List 14 0Q7?240M 1&$F041% 4BN@!0N4 10N01&1? LA8&28&$ 29%@1A$G AN940$@# L&81!NA8 A2OFAN(10187&1?3

19. Assertive Recruitment Through Jail, Shelter, Hospital In-Reach 15

20. Supportive Housing Section 8 Housing Choice Vouchers (or State rental assistance programs) + Mobile Intensive Case Management Services Unit set-asides in new supportive housing buildings or existing supportive housing with turnover Providers trained in Motivational Interviewing, navigating criminal justice system, harm reduction, recognizing “symptoms” of incarceration 16

21. “Systems Change” Through Case Coordination Monthly implementation monitoring meetings to track recruitment, housing placement, housing retention, and recidivism prevention Case conference and intervention in cases of re-arrest or re-hospitalization Puts supportive housing provider at center of “system of care” 17

22. Measure Outcomes and Cost-Effectiveness Crisis services use ($) 2 years before FUSE — Crisis services use ($) 2 years after FUSE — FUSE cost over 2 years Net Savings/(Cost) of FUSE over 2 years 18

23. 19 New York City FUSE DHS DOC Neither System Demonstration program designed to test whether PSH with enhanced engagement services can break cycle of homelessness and incarceration among individuals who are known “frequent flyers” of jail and shelter Supportive housing with “front-loaded” intensive case management services for 190 frequent users of jail and shelter, identified through pre-generated data match

24. Implementation through Collaboration 20

25. 21 FUSE I Resources and Models 50 Single-site (Congregate) supportive housing with front-loaded intensive services 50 Scattered-site supportive housing with front-loaded intensive services --------------------------------------------- Total: 100 units of supportive housing with FUSE 50 NYCHA Section 8 vouchers (Project Based) 50 existing single-site supportive housing unit set-asides Supportive services funded through other existing sources (e.g. COBRA, HUD) $650,000 from JEHT Foundation for service enhancements + $80,000 for training and TA

26. 22 FUSE II Resources and Models 40 NYCHA Section 8 vouchers (Project Based) 20 HPD Section 8 vouchers (Tenant Based) 16 NY/NY subsidies and services 17 existing supportive housing unit set-asides $604,500 from NYC DOC and DHS for service enhancements $250,000 from Langeloth Foundation for evaluation 17 Single-site (Congregate) supportive housing with front-loaded intensive services 73 Scattered-site supportive housing with front-loaded intensive services --------------------------------------------- Total: 90 units of supportive housing with FUSE

27. Providers and Units 23

28. 24 Characteristics & Service Needs of Jail-Shelter Frequent Users High rates of co-occurring and complex issues: Alcohol and substance use (approx. 80%); earlier data matches found high utilization of crisis drug treatment services (i.e. Medicaid-reimbursed detox) Mental health issues (est. 30-50%), including serious mental illnesses (est. 25-40%) Criminal offenses largely consists of low-level misdemeanors (i.e. “quality of life” crimes), with minor felony histories Histories of transience and high level of involvement in multiple systems and services Lack of trust in service providers and inconsistent benefits enrollment Limited independent living skills and history of chaotic and unstable behaviors

29. 25 NYC Frequent Users of Jail and Shelter Phase I Evaluation Results Two years after placement into housing with services, tenants have experienced: 91% housing retention rate 92% reduction in use of homeless shelters 53% reduction in use of city jails

30. Jail-Shelter Cost Offsets from FUSE 26

31. Other FUSE Replications Implementation Cook County, IL Hennepin County, MN Connecticut Seattle, WA Denver, CO Washington, DC Planning Franklin County, OH Newark, NJ Detroit, MI Los Angeles, CA Richmond, VA Austin, TX 27

32. Improved Understanding of Problem Multi-agency, cross-sector planning and analysis led to reframing of problem: Not “career criminals” or jail  shelter discharge, but an “institutional circuit” across multiple systems Shift from finger-pointing to shared ownership of problem 28

33. Development of Comprehensive Solution and Pooling of Resources Solution was not improved jail discharge planning or improved shelter services, but supportive housing to address housing, criminogenic, and behavioral health service needs at once Resources pooled from multiple sectors and systems (corrections, homeless services, housing, behavioral health, and philanthropy) Joint government-community implementation process allows for troubleshooting at all levels 29

34. Creating Person-Centered Systems of Care and Response Shifting resources from institutions to housing and services Changing the housing prioritization paradigm from “first come, first serve” to reaching most needy and costly Shift housing provider rolefrom passive “tenant selection” to active “in-reach and recruitment” 30

35. For More Information Richard Cho Director, Innovations & Research Richard.cho@csh.org 31