Housing Is Healthcare: Improving Health Outcomes for Homeless People Living with HIV/AIDS

Laura Grund

New York State Supportive Housing Conference June 9, 2011

Overview of Presentation

Presentation Overview

• Harlem United • Housing= HIV/AIDS Healthcare • Foundation House West • NY/NY III • Client Profile • Questions

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Harlem United

• “One-stop shop” with integrated medical, housing, prevention, and supportive services for PLWHA • Our mission: to provide 100% access to care and to obtain zero disparity in health outcomes caused by socioeconomic barriers • 558 units of housing for adults and families living with HIV/AIDS (plus HIV primary medical and dental care [FQHCs], psychiatry, mental health, substance use, adult day health care, intensive case management, Voc Ed employment services and prevention services) 3

HOUSING = HIV HEALTHCARE

• Studies show strong correlations between improved housing status and… – Reduction in HIV/AIDS risk behaviors – Access to education and prevention – Improved health outcomes – Savings in taxpayer dollars • Reduced utilization of emergency & inpatient services, lower overhead costs compared to shelters and other emergency housing services • Savings have been found to offset up to 95% of the cost of supportive housing (findings from “National Housing & HIV/AIDS Research Summit

Series” – The Johns Hopkins Bloomberg School of Public Health)

• Harm reduction-based housing services increase routine utilization of medical care, improve medication adherence and health outcomes, and increase rates of employment among our clients 4

• 25 congregate units, single adults living with HIV/AIDS, histories of homelessness, chronic health diagnoses • Program mission: to assist residents in attaining personal medical and housing stability and independent living skills • Supportive case management; life skills services; vocational, employment and educational services; primary medical and home care referrals; entitlement assistance and advocacy; substance use assessment and Harm Reduction education and counseling; mental health assessment and counseling; etc

Foundation House West

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Demographics of FHW

Demographics: Residents are predominantly male (88% male; 12% female) African American (63%); 33% Latin, and 4% white Median age of 46.3

All residents are triply-diagnosed with a history of substance use, 85% with a psychiatric diagnosis, 90% with another non HIV related co-morbid condition such as diabetes, asthma, heart or lung disease 6

Hospital Utilization, Foundation House West

Hospital Utilization Prior to and After Placement at Foundation House West 70% 60% 50% 40% 30% 20% 10% 0% 54% ER V isit s 6 M o nt hs Pio r t o Placement 42% ER V isit s 6 M o nt hs af t er Placement 63% 46% Ho sp it aliz at io ns 6 M o nt hs Pr io r t o Placement Ho sp it aliz at io ns 6 M o nt hs af t er Placement

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Hospital Utilization, Foundation House West

Frequency of ER Visits Prior to and After Placement 3 2 1 0 7 6 5 4 5.87

1.46

Number of visits to the ER 6 Months Prior to Placement Number of visits to the ER 6 Months After Placement

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Cost Benefit Analysis of Foundation House West

The cost benefit of supportive housing for PLWH/A has been demonstrated by the decreased dependence and need for

inpatient hospital care.

Likewise, the decrease in FHW clients’ frequency of inpatient

hospitalizations yielded overwhelming savings in

comparison to the overall cost of this congregate program.

to Placement at FHW to Placement at FHW

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FHW

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NY/NY III Scattered Site Housing

• 70 units of housing coupled with supportive services to chronically homeless single adults who are living with HIV/AIDS and co occurring serious mental illness, substance use, or both • NY/NY III works with residents to stay healthy using a multi disciplinary team approach. The team includes Case Managers, a Nurse, a Vocational/Educational Specialist, and a Mental Health Specialist. All members of the team provide services to residents within their homes or in other community settings at least twice a month 11

Demographics:

Gender:

69% Male 24% Female 7% Transgender Race: 66% Black/African American 19% White 1% American Indian/Alaska Native 1% Multi-racial 13% unknown

Ethnicity:

27% Latino/a

NY/NY III Population Overview

Gender Male Female Transgender Race Black/African American White American Indian Multi-racial Unknown 12

NY/NY III

Services include medical monitoring and medication adherence; mental health counseling and referral; substance use counseling and referral; life skills training including vocational, employment and educational services; apartment care and maintenance ; advocacy and case management; linking/referrals for legal assistance and other entitlements; escorts to medical, mental health, entitlements, and all other appointments; etc Utilizes multi-disciplinary model that incorporates aspects of an ACT team 13

NY/NY III

70% of clients classified as high risk and have some other serious illness or diagnosis; more than half (55%) present multiple risk factors requiring increasingly individualized multidisciplinary HIV/AIDS services

Classification of High Risk Due to One or More of the Following

n=150

16% Multiple Factors Med-Psych Med-Behavioral Substance Psychiatric Illness Behavioral SubstanceIssue Medical Status 0% 5% 7% 8% 10% 15% 16% 20% 22% 25% 30% 31% 35%

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NY/NY III

Substance Use & Adherence to Mental Health Treatment Comparison Between High and Low Risk Clients

n=216

60% 50% 40% 30% 20% 10% 0% 50% 27% 10% 1% % of High Risk Clients % of Low Risk Clients 38% 19% % of total Sample Substance Use Not in care for MH Issue

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Hospital Utilization, NY/NYIII Clients

Assessment of NY/NYIII Utilization Emergency Room Visits (n=64)  Average # of visits  ER visits resulting in hospitalization Hospitalizations (n=64)  Frequency of hospitalization  Average length of stay Six Months Prior Six Months to Move-in After 42% 1.81 visits 48% Placement 27% 1.12 visits 53% 38% 1.67 hospitalizations 9.42 days 25% 1.33

7.13 days 16

[1] Cost of emergency room visits $832 hospital stay $1,891. Source of Emergency Room Cost based 2003 cost data from Medical Expenditures Panel Survey. Research and Quality January 2006.

Source of Hospitalization Cost based on 2007 numbers from Agency for Healthc [2] ER Cost $832 x 49 ER visits = $40,768. Hospital $1891 x 226 days spend hospitalized = $427,366

Analysis of NY/NY III

[3] ER Cost $832 x 19 ER visits = $15,808 Hospital $1891 x 114 days spend hospitalized = $215,547 [4] Unit of Analysis is the total number of emergency room visits and the total number of days spent in the hospital prior to and then after program intervention. Cost Benefit of A. Cost of Hospital NY/NYIII Visits Six Months Hospital) Estimated Cost $468,134 B. Cost of Hospital Visits Six Months Hospital) $231,355 C. Saving in reduced Prior to Placement After to Placement Hospital Visits (ER Visits + Days in (ER Visits + Days in by Program (Column A-B) $236,779 17

Client Profile

• • • • CH was referred to HU Supportive Housing in July 2010 by his Case Manager at HU’s Adult Day Health Care West due to inadequate housing. At the time of intake, CH was four months sober and focused on remaining sober, returning to the work force and improving his relationship with his 12 year old daughter. CH was housed in September 2010 and immediately began to seek employment. Although the client is legally blind and uses a walking stick, he obtained full time employment as a Service Coordinator at a non-profit organization working with individuals with a history of substance use and homelessness. The client has a current goal of working towards his CASAC. Since obtaining his own apartment, the client has been able to take advantage of every other weekend visits with his daughter and have a home he feels comfortable sharing with her. He remains sober and says he is very happy with his job and looks forward to a future of employment and greater independence. 18

Policy Implications

Take Aways…

• Supportive Housing for PLWHA is Healthcare -- increases access to medical care, decreases acute care, improves health • Supportive housing as form of Prevention for those at risk (HIV negative, unstably housed); homelessness/eviction prevention • HU housing clients healthier, leading full and productive lives; emphasis on employment and ultimately moving on from supportive housing 19

Contact Information

Questions?

Laura Grund Vice President of Supportive Housing HIV/AIDS Treatment Support Services Harlem United Community AIDS Center, Inc.

306 Lenox Avenue, 3 rd floor New York, NY 10027 (212) 803-2850 [email protected]

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