Transcript Document

Cost Savings from
Permanently Housing
Frequent Users of
Hospitals
Orange County Business Council
March 31, 2014
Susan Lee, Senior Program Manager, Los Angeles
[email protected]
Our Mission
Advancing housing solutions that:
Improve lives of
vulnerable
people
Maximize public
resources
Build strong,
healthy
communities
Maximizing Public Resources
CSH collaborates with communities to introduce housing solutions
that promote integration among public service systems, leading to
strengthened partnerships and maximized resources.
Public
Systems
Housing
Health Care
Criminal Justice
Child Welfare
Maximized
Resources
Building Strong, Healthy Communities
Locations where CSH has staff stationed
Locations where CSH has helped build strong communities
Homelessness is an institutional circuit
Drug
Treatment
Shelter
Psych
Center
Jail
Hospital
Detox
Street
Emergency
Room
Highest-Need, Highest-Cost 10%
New York: Medicaid Beneficiaries
Los Angeles: Homeless Individuals
10% use 57% of healthcare resources
10% use 72% of healthcare resources
100%
58,000
$420 million
10%
80%
72%
60%
40%
90%
20%
Most costly
10%
Least costly
90%
28%
0%
Patients
Spending
6
Housing is Health Care
Randomized, control-group, pre-post, pilot evaluations
2002
2008
2009
2011
2013
The strongest healthcare intervention for high
utilizers is supportive housing
18-Jul-15
8
CSH Los Angeles Frequent User Programs
Target:
The “10th decile,” the highest-need, highest-cost 10% of homeless
persons in LA County
Problem:
For chronically ill homeless individuals who
continually move in and out of high-cost
healthcare services, health outcomes
deteriorate, and for healthcare systems, costs
escalate.
Goal:
Solution:
To provide continuity of care from the hospital
to the community, stabilize health outcomes in
supportive housing, and reduce healthcare
system costs for chronically homeless frequent
users in the 10th decile.
Permanent supportive housing with intensive
case management and care coordination and
wrap-around services.
FUSE/SIF to Date
In Permanent
Supportive Housing
Total Active Clients
100
145
199
Total Originally
Enrolled
Total Clients
Screened
341
The 10th Decile: the underlying research base
The greatest cost savings can be achieved by prioritizing high-risk individuals
$7,000
Probation
One
decile individual’s
annual public cost: $78,348
10th
Economic
Roundtable
Sheriff mental health
jail
$6,000
Sheriff medical jail
Sheriff general jail
$5,000
Average Monthly
Costs in All Months by
Decile for Homeless
GR Recipients
Source: 2,907 homeless GR recipients in
LA County with DHS ER or inpatient
records
LAHSA homeless
services
GR Housing
Vouchers
$4,000
One 10th decile individual’s
annual hospital cost: $41,424
General Relief
Food Stamps
$3,000
Paramedics
Public Health
$2,000
Mental Health
Private hospitals-ER
$1,000
Health Srv - ER
Highest Decile
Ninth Decile
Eighth Decile
Seventh Decile
Sixth Decile
Fifth Decile
Fourth Decile
Third Decile
Second Decile
$0
Lowest Decile
LA County CEO office’s Service
Integration Branch (SIB) linked
service and cost records across
county departments for a
representative sample of General
Relief (GR) recipients to produce
this exceptionally valuable data
Crisis Indicator: Triage Tool for Identifying Homeless Adults in Crisis. Economic Roundtable. 2011.
Where We Sleep: Costs when Homeless and Housed in Los Angeles. Economic Roundtable. 2009.
Health Srv
outpatient clinic
Private hospitalsinpatient
Health Srv hospitalinpatient
10
FUSE+SIF Communities
Regions
D
A
E
B
C
F
G
A
B
C
D
E
F
G
Westside
Downtown
Boyle Heights
San Fernando Valley
Glendale
Pasadena
East San Gabriel Valley
11
18-Jul-15
FUSE+SIF Structure
Westside
Downtown
SIF
Economic
Roundtable
CSH
Pasadena
Glendale
Boyle
Heights
FUSE
SFV
East SGV
18-Jul-15
OPCC
VFC
St. John’s
Health
Center
Santa
Monica
UCLA
Homeless
Health Care
LA
LAC+USC
Olympia
Medical
Center
Housing
Works
JWCH
Housing
Works
CHAP
California
Hospital
Huntington
Hospital
Homeless
Health Care
LA
Alhambra
Medical
Center
Ascencia
CCHC
Glendale
Memorial
Housing
Works
White
Memorial
LAFH
SFVCMHC
NEVHC
YWCA SGV
Pomona
CHC
Mission
Community
Hospital
Homeless Services
Providers
FQHCs
Hospitals
Pomona
Valley
Hospital
Glendale
Adventist
Kaiser
LAMC
Kaiser
Woodland
Hills
Kaiser
Panorama
City
12
2013 FUSE/SIF Evaluation:
Baseline Profile of Referrals
Sex
Race
Age
Jail or probation
ER visits
Hospital admits
• 71% male
• 29% female
•
•
•
•
•
43% African American
23% European American
15% Latino
3% Asian/Pacific Islander
4% Other
• Average: 48 years old
• 68% > 46 years old
• 29%
• 18 per person average in
24 months before referral
• 7 per person average in 24
months before referral
Hospital inpatient
days
• 31 per person average in
Chronic physical
disability
• 90%
Mental disorder
• 78%
• schizophrenia
• bipolar disorder
• depression
Substance abuse
• 53%
• alcohol
• drugs
13
24 months before referral
74% co-occurring disorders
42% tri-morbidities
average cost per inpatient
day: $2,566 in CA
•
•
•
•
•
•
•
hypertension
heart failure
diabetes
rheumatism
liver disease
venous embolism
chronic pulmonary disease
13
Supportive housing can be integrated with health
providers and a health services delivery network
• Many newly enrolled adults are likely to have multiple
chronic health needs, including mental illness and
substance abuse.
• In the absence of effective care management and care
coordination, these beneficiaries may face poor health
outcomes, otherwise preventable hospitalizations, and high
levels of medical expenditures.
• A few communities have begun strengthening the
integration between supportive housing and healthcare by
creating partnerships between housing providers and
healthcare providers including Federally Qualified Health
Centers (FQHCs), hospitals, and others.
14
18-Jul-15
FUSE+SIF Model for Health Care Delivery
Collaboration
10th Decile triage tool
hospitals, FQHCs,
homeless services
highest-cost, highest-need
10% of homeless individuals
Health Homes
intensive case
management/ care
coordination
Permanent
Supportive
Housing
The Glue: Intensive Case Management
i.e., Care Coordination + Housing Navigation
housing navigation
and retention
PRIMARY CARE
BEHAVIORAL HEALTH
SUBSTANCE ABUSE
FREQUENT
USERS
18-Jul-15
NAVIGATOR
SUPPORTIVE HOUSING
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Permanent Supportive Housing
What is Permanent Supportive Housing (PSH)?
 For individuals or families who are homeless
 Housing where all tenants have access to voluntary services

Increases housing retention by addressing substance abuse, mental illness, and chronic
health issues and by using the Housing First philosophy
 Housing for which the tenant pays no more than 30% toward rent &
utilities
 Tenant can stay as long as they wish; no time limit
 Property manager lives onsite; services staff onsite
 PSH is not a shelter, hospital, half-way house, substance abuse rehab
facility, group home, public housing or transitional housing
FUSE/SIF Hospital Utilization and Cost Avoidance (Actuals)
81% Average Decrease In Total Costs Per Client Per Year
ER utilization down 71%
Hospital readmissions down 85%
Inpatient days down 81%
ER costs down 66%
Inpatient costs down 83%
Total costs decreased 81%
FUSE Hospital Utilization
Hospital Cost Avoidance
Pre- and Post-Enrollment
Pre- and Post-Enrollment
average per person, n=60
$59,416 average per person, n=60
Costs not charges
12 mos before
12 mos before
12 mos in program
$73,333
28.6
9.8
12 mos in program
$65,799
8.5
2.8
ER visits
5.5
$7,534
1.2
IPT admits
IPT days
$11,391
$13,918
$2,527
ER costs
IPT costs
Total cost
Average cost avoidance per person: $60,000
Largest individual cost avoidance: $2.2 million
25% of the cohort avoided costs in excess of $100,000
Source: FUSE/SIF hospital cost data, September 2013
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18-Jul-15
FUSE+SIF Client Hospital Utilization by Hospital
Emergency Room Visits
Inpatient Admissions
Inpatient Days
Average # visits per patient,
n=60
Average # admits per patient,
n=60
Average # days per patient,
n=60
9.8
28.6
8.5
2.8
5.5
1.2
12
mos in
FUSE/
SIF
Hospital A
10.0
1.4
Hospital B
5.2
0.2
-
Hospital C
3.0
-
2.8
0.5
Hospital D
57.3
5.0
26.0
3.1
Hospital E
78.6
14.9
1.2
Overall
Average
28.6
5.5
12
mos in
FUSE/
SIF
Hospital A
2.4
0.5
Hospital B
1.0
0.2
0.4
Hospital C
1.0
22.8
12.4
Hospital D
7.6
1.9
Hospital E
2.8
Overall
Average
12
mos in
FUSE/
SIF
Hospital A
8.9
2.1
Hospital B
15.1
4.1
Hospital C
3.0
Hospital D
Hospital E
Overall
Average
Baseline 12
mos
Baseline 12
mos
Baseline 12
mos
9.8
8.5
Source: FUSE/SIF hospital cost data, September 2013
18-Jul-15
18
Total Public Cost Avoidance for 10th Decile
$47,977 in estimated annual public costs avoided by housing 10th decile patients
$70,000
$67,376
Probation
n = 89
$67,376 when homeless
$19,399 when in PSH
Navigation and housing
costs not included
Sheriff medical jail
Sheriff general jail
Annual Cost in 2012 Dollars
Estimated annual
public cost for 10th
decile patients in
evaluation, using
propensity scoring:
Sheriff mental health jail
$60,000
$50,000
LAHSA homeless srv.
GR Housing Vouchers
General Relief
$40,000
Food Stamps
Paramedics
$30,000
Substance abuse srv.
$19,399
$20,000
Mental Health
County outpatient clinic
Private hospitals-ER
Health Srv - ER
$10,000
Private hospital-inpatient
County hospital-inpatient
$0
When Homeless
In Permanent
Supportive Housing
Getting Home: Outcomes from Housing High Cost Homeless Hospital Patients
The
19 Economic Roundtable, September, 2013
Bottom Line: $6 in cost avoidance for every $1
spent on funding FUSE services
$47,977
estimated annual public costs avoided by housing 10th decile patients
(gross cost avoidance)
$15,159
$6,518
estimated first-year costs to
house each patient
estimated annual housing and
supportive service subsidy in second
and subsequent years
$31,736 or 66%
$40,377 or 84%
net public costs avoided in the
first year
net public costs avoided
$2 in cost avoidance for
every $1 spent in first year
$6 in cost avoidance for
every $1 spent in years 2+
Getting Home: Outcomes from Housing High Cost Homeless Hospital Patients, The
Economic Roundtable, September, 2013
18-Jul-15
20
SIF Client: Popeye
 Popeye, 53, has been a fixture in Pasadena on
the freeway off-ramp for the past 15 years. In
the fall of 2012, he spent two months in
Huntington Hospital, in a two-week coma.
 He moved into his one-bedroom apartment in
December 2012, and his case manager helped
him connect with Community Health Alliance of
Pasadena as his medical home, and handle his
finances through money management.
 Popeye has quit panhandling and gets regular
visits from his case manager to help him shop,
cook and keep clinic appointments.
18-Jul-15
21
Triple Aim alignment
Improving
Quality
of Care
Reducing
Costs
• Reduced readmissions to ED
and hospital
• Cost avoidance in ED and
inpatient care
Improving
Health
Outcomes
• Continuity of care from
hospital to community:
patients get care they need
• More appropriate use of ED
space and staff
• FUSE stabilizes very fragile
individuals through housing
and intensive case
management services
What it takes to fund FUSE/SIF
Program Cost per person Year 1
$16,000
Rental subsidies
$14,000
$4,500
Household supplies
$12,000
Furniture
$10,000
$1,562
$8,000
$2,519
Security deposits
Temporary housing
Patient transportation
$6,000
$2,700
$4,000
$2,000
$0
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Housing navigation
Care coordination
$2,700
$750
Screening and outreach
TA and evaluation
Health Home = Virtual “Home” for Addressing
Health-Related Needs
AB 361. “Health
Homes” Bill
Utilizes a federal option under ACA
to provide health home services
for key patient populations, including
frequent hospital users and
chronically homeless Medi-Cal
beneficiaries
Individua
l and
family
supports