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1 Session Starting Shortly! Everyone is muted to reduce background noise. Have a question? Type into the Chat box. Enable Chat by clicking the icon in the top right corner. Audio Trouble? Option 1 Log off and restart the event. Option 2 Chat to Host. As soon as the recording is available, we will send you the slides, a link to the recording, and answers to questions that we weren t able to get to today.

2 Understanding Data Elements and Outcome Measures in Health and Housing Partnerships The Source for Housing Solutions April 27, 2017

3 Our Mission Advancing housing solutions that: Improve lives of vulnerable people Maximize public resources Build strong, healthy communities

CSH HRSA Frequent User T/TA GOALS: Foster and expand Health Center collaboration with other health system stakeholders, and supportive housing Improve healthcare outcomes for extremely low-income

4 CSH HRSA Frequent User T/TA GOALS: Foster and expand Health Center collaboration with other health system stakeholders, and supportive housing Improve healthcare outcomes for extremely low-income individuals who frequently use crisis systems, have housing instability, and lack a connection to primary and preventive care services. Webinar Series Direct Technical Assistance Online & In-Person Trainings Peer to Peer networks Resources PARTNERS: Deep collaboration with Also partnering with: NACHC CHPS HRSA BPHC Visit us on the Web:

5 Today s Panelists Rhonda Hauff, Chief Operating Officer, Yakima Neighborhood Health Services Jane Bilger, Senior Program Manager, CSH PiaValvassori, Nurse Practitioner, Orange Blossom Family Health Lauryn Berner, Project Manager, National HCH Council Dewey Wooden, Director of Behavioral Health, Orange Blossom Family Health

6 Understanding Data Elements Building on the Early Evidence Learn about data collection capabilities in the health and housing sectors Data Elements & Outcomes in the Health and Housing Sectors Understand what health outcomes other communities are tracking Examples from the Field: Yakima, WA & Orlando, FL Hear examples from the field Questions and Answers

7 Understanding Data Elements Building on the Early Evidence Data Elements & Outcomes in the Health and Housing Sectors Examples from the Field: Yakima, WA & Orlando, FL Questions and Answers

8 Homelessness & Health Poor physical and behavioral health causes homelessness Homelessness causes new physical and behavioral health issues Recovery and healing are more difficult without housing Individuals experiencing homelessness have high rates of acute and chronic illness

9 Health Status of Health Center Users by Housing Status 80% 70% 60% 50% 40% 30% 20% 10% 0% 72% 54% 27% 21% 19% 16% 16% 11% 3% 1% 5% 2% 25% 12% Homeless Non-Homeless

10 What We Know: Performance Outcomes San Francisco study found 5-year survival rates of 81% for PLWAs in supportive housing compared with 67% who remained homeless Chicago study found 55% survival for PLWAs in supportive housing compared with 35% of control group, and lower viral loads among housed group Denver study found 50% of tenants improved health status and 43% had improved Mental Health Seattle study found 30% reduction in alcohol use among chronic alcohol users in Supportive Housing

11 What We Know: Costs and Savings Direct Access to Housing in San Francisco found that supportive housing reduced nursing home costs by $24,000. In Portland, Maine Medicaid costs were reduced by almost $6,000 due to supportive housing. Downtown Emergency Shelter Center in Seattle showed 41 percent in Medicaid savings by reducing ER visits and hospital inpatient stays.

12 Data and Outcomes: Why Do More? Demonstrate value Build interest and champions within the health center Create an evidence base to engage additional partners Improves the quality of life of consumers Increase housing stability Improve overall service delivery Increase community support and investment in supportive housing Improve health outcomes

13 Whiteboard Questions Hint: Click pencil icon (top-left and Text tool icon to type your responses here. 1. What challenges do you have collecting or analyzing data related to health outcomes in housing? 2. What health outcome measures are you interested in tracking related to housing?

14 Understanding Data Elements Building on the Early Evidence Data Elements & Outcomes in the Health and Housing Sectors Examples from the Field: Yakima, WA & Orlando, FL Questions and Answers

Health Outcomes and Data Measures: A Quick guide for Health and Housing Partnerships INTRODUCTION Partnerships between health centers and supportive housing providers employing a Housing First

15 Health Outcomes and Data Measures: A Quick guide for Health and Housing Partnerships INTRODUCTION Partnerships between health centers and supportive housing providers employing a Housing First approach 1 have shown reductions in emergency department utilizations, inpatient hospital stays, and costs to the health system, increased use of preventative primary and behavioral health care as well as high rates of housing retention. 2 Clinical outcomes assessing changes in mental health status and a reduction in substance use is linked to Housing First programs, yet few studies or reports have addressed the impact of these programs on physical health outcomes such as diabetes, blood pressure, and asthma. 2 As more health centers look to establish partnerships with housing providers or even begin delivering services to residents in supportive housing 3, they are starting to look at which physical health outcomes to track as part of housing programs. This quick guide will help communities understand the key health conditions experienced by homeless individuals that may be positively impacted with stable housing and the data elements generally tracked within the homeless health and housing sectors. This guide is designed to increase familiarity with measures already being tracked, enabling health and housing partnerships to leverage existing data and reduce administrative burden related to developing new mechanisms to track and report data. Demonstrating improved health outcomes through health and housing partnerships not only builds interest and champions within the health center, it provides an evidence base to engage additional partners, including hospitals and managed care organizations. These entities already have a vested interest in improved health outcomes and shifting to primary and preventive care as appropriate, making them natural partners. From the housing side, improved health outcomes improves the quality of life of consumers, increases their housing stability, and helps improve overall service delivery. Demonstrating the impact of housing on health outcomes also shows the value of supportive housing, which can increase community support and investment in supportive housing. 1 Project profiles and additional resources available at 2 CSH, Housing is the Best Medicine: Supportive Housing and the Social Determinants of Health, 2014, 3 Note that permanent supportive housing and supportive housing are used interchangeably in this publication

16 Impact Areas Chronic Health Conditions Treatment and Medication Management Acute Conditions Insurance Coverage Emergency Room Utilizations & Hospital Inpatient Stays Mental Health Screenings Substance Use Screening & Treatment

Preventive Services Enabling Services ICD-10 Medical

17 Health Center Data UDS Selected Medical Conditions Mental Health & Substance Use Diagnostics, Screening, Preventive Services Enabling Services ICD-10 Medical Conditions Mental Health & Substance Use Social Factors

18 Housing Data Demographic Information Disabling Condition Universal Data Elements Living Situation HMIS Project Entry/Exit Date Destination Program Specific Data Elements Health Related Data

19 Housing Data Health Insurance Chronic Conditions Disability Health Related Data Substance Use HIV/AIDs Mental Health

20 Where do they overlap? Housing Status Chronic Conditions Health Insurance HMIS Acute Conditions ICD- 10 UDS Mental Health HIV/AIDS Substance Use Disability

21 What do other communities track? Obesity Service Engagement Diabetes Substance Use Health Functioning Vital Signs Mental Health Quality of Life Criminal Justice Involvement Perception of Health Status Connect to Primary Care Emergency Room Visits Income Hypertension Preventive Screenings Hospitalizations Housing Retention

22 Understanding Data Elements Building on the Early Evidence Data Elements & Outcomes in the Health and Housing Sectors Examples from the Field: Yakima, WA & Orlando, FL Questions and Answers

23 Yakima Neighborhood Health Services Overview of your programs. How have you linked health and housing data? What challenges did you face and how did you overcome these data challenges? What have you learned? How have you used data to make system changes?

affordable, quality health care, promote learning opportunities for students of

24 Yakima Neighborhood Health Services Improving Quality of Life in Our Communities The Intersection of Housing and Health Care YNHS Mission To provide accessible, affordable, quality health care, promote learning opportunities for students of health professions, end homelessness and improve quality of life in our communities.

25 How We Connect in our Communities YNHS Sunnyside Campus Henry Beauchamp Community Center Comprehensive Health Services Neighborhood Treatment Services Granger Dental Granger Medical Sunnyside Walmart Plaza Supportive Housing The Depot Lower Valley Mobile Unit

26 2016 Profile Some Patients Need a Little -- Some Need EVERYTHING All Primary Care Patients 22,310 Primary Care Visits 82,623 Mental Health Visits 3,544 Homeless Patients 2,232 Medical, Dental, Mental Health Visits Permanent Supportive Housing- Fed/State/Local 10, households 134 people Prescriptions Filled 106,118 Enrolled WIC Clients 8,058 Affordable Care Act Applications 6,114 Extreme Weather Shelter Nov 17 current Medical Respite Housing & Essential Needs (HEN) 260+ people 2,000 + nights 58 People 1,287 nights 248 households

27 Safe, Affordable Housing + Case Management = Supportive Housing Individuals Families

28 Permanent Supportive Housing (Yakima - Toppenish - Granger Grandview) 90 Units + HEN Assistance Toppenish - 2 McKinney units Granger - 2 McKinney units Grandview 8 McKinney units Sunnyside - 4 McKinney units Yakima 49 McKinney units, Yakima - 25 HURAY units 100+ HEN clients receiving rental assistance)

29 1. We have to focus on solutions. 2. Chronic homelessness is not a quick fix. 3. Permanent Supportive Housing and Supportive Employment are solutions that work. 4. Yakima has made significant progress. Homeless Network of Yakima County Reducing homelessness in our communities Unshelte red Unsheltered Sheltered

3,500 3,000 2,500 2,320 People Entered into HMIS 3,083 3,066 Point in Time Count 2,473 Last year in WA State, 64,851 people were entered into the state HMIS system (received services), and 20,844

30 3,500 3,000 2,500 2,320 People Entered into HMIS 3,083 3,066 Point in Time Count 2,473 Last year in WA State, 64,851 people were entered into the state HMIS system (received services), and 20,844 were counted during the annual PIT count. HUD estimates for every person counted during PIT, 2 people are not counted. 2,000 Pop 251,133 2,130 Pop 252,26 Pop 201,140 2, Pop 243,231 1,500 1, Kitsap Thurston Whatcom Yakima

31 31

32 Demographic and Clinical Outcomes 32

33 Electronifying Arizona Self Sufficiency Assessment 33

34 Social Determinants built into E.H.R.

35 UDS Table 4 - Health Coverage Respite Respite 77% Respite 23% PSH PSH 87% PSH 13% Homeless Homeless 86% Homeless 14% Agricultural Agricultural 81% Agricultural 29% All Users All Users 85% All Users 15% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 35

36 Multi-Disciplinary Approach One Record

AVERAGE RESPITE STAY IN 2016 = 22 DAYS Daily

Transport / accompany to PCP and specialty

37 AVERAGE RESPITE STAY IN 2016 = 22 DAYS Daily checks by Nurse / Behavioral Health / Case Manager. Wound care. Behavioral Health counseling. Transport / accompany to PCP and specialty and OT/PT appointments. Evaluate and support ADLs. Assist with applications for SSI/SSDI, Basic Food and other federal/state benefits. Facilitate family interaction when possible. Initiate housing stabilization. Provide discharge summary to patient /PCP at time of respite exit.

38 58 patients stayed 1,287 Days- Here s Why Length of Stay People Reason for Respite Needed One Week or Less 34% Ulcers, wounds, abscesses, post-surgery recovery 1 to 2 weeks 22% MRSA, abscesses, cellulitis, wound care 2 4 weeks 33% Fractures, cancer / chemotherapy 4 weeks or longer 33% Necrotizing fasciitis, amputation recovery, fractures Sicker population than previous years

39 Medical Respite Care Saves $$ Hospital Staff Report a Saving of 109 Inpatient Days in 2016 ($135,269 for Depression or $392,400 for Rehab) Respite care reduces public costs associated with frequent hospital utilization. Average Length of Stay Average Charge Per Patient Average Charge / Cost per Day Average Hospital Charge for Depression* Average Hospital Charge for Rehab* Average Respite Program 13 days 8.1 days 22 days $16,133 $29,16 $3,710 $1,241 $3,600 $ *WSHA Hospital Pricing

50.00 Case Managers add a lot to the Story Visits by User (2016) 45.00 43.42 40.00 35.00 34.91 30.00 25.

40 50.00 Case Managers add a lot to the Story Visits by User (2016) Universal Visits Agricultural Visits Homeless Visits PSH Respite

41 90% UDS Table 7 - Controlled Diabetes (HbA1c is Measured and less than 9) 80% PSH 78% 70% 60% Universal 57% Respite 62% 50% 40% 30% 20% 10% 0% Universal PSH Respite 41

42 90% 80% UDS Table 7 - Controlled Hypertension (Most recent Blood Pressure is Less than 140/90) 77% 84% 70% 64% 60% 50% 40% 30% 20% 10% 0% Universal PSH Respite 42

43 2016 PSH / Respite Targets Fragile Patients UDS Table 6A -Patients with at least one Mental Health Dx During the Year (Depression, Anxiety, PTSD, Attention Deficit, etc.) 60% Inter-disciplinary teams are needed to serve high needs individuals and families 50% 40% 30% 45% 50% 46% Primary Care Mental Health Chemical Dependency 20% 10% 23% 10% Domestic Violence 0%

44 40% UDS Table 6A - Flu Vaccine 35% 35% 34% 30% 25% 27% 27% 24% 20% 15% 10% 5% 0% Universal Agricultural Homeless PSH Respite 44

45 The Bottom line Once Housed.. Mental Health Improves Less disruptive Infectious disease rate improves Pain is better controlled Medications better managed Treatment plans compliance improves More likely to obtain and maintain employment or education 45

46 Orange Blossom Health Care for the Homeless Overview of your programs. How did you decide what to track? Are you linking data community wide or internally? What challenges did you face and how did you overcome these data challenges? What have you learned? How have you used data to make system changes?

47 Health Care Center for the Homeless Understanding Data Elements and Outcome Measures in Health and Housing Partnerships Health Care Center for the Homeless Orange Blossom Family Health

48 Health Care Center for the Homeless Overview 330 h funded Health Center Health Care for the Homeless Federally Qualified Health Center Over 15,000 patients (55% Homeless) 154 employees, $11 Million budget Medical, Dental, Behavioral Health, Pharmacy D.b.a Orange Blossom Family Health (6 satellite clinics) Orange, Osceola, Seminole Counties Florida is a non-expansion state (Medicaid)

49 Health Care Center for the Homeless Our Community s Call to Action 2013, Worst area for homelessness in midsized Metropolitan areas 2013/14, Several homeless community members died on the streets awaiting housing Media attention on specific cases Central Florida Commission on Homelessness Collaboration of Business and Community Leaders Commitment to study the cost of long term homelessness in Central Florida

50 Health Care Center for the Homeless

51 Health Care Center for the Homeless Our Community s Response The Plan.. Mayor Buddy Dyer - $1 million, house 300 chronically homeless persons in 3 years End Veterans Homelessness by December 2015 Housing First philosophy Orlando Magic, Walt Disney World, Universal Studios all committed resources Florida Hospital private match $6 million over 3 years case management and supportive services

52 Health Care Center for the Homeless Housing First Housing the first Project Intensive Case Management (ICM) 1:17 Case management ratio Coordinated Entry System (CES) with local CoC VI-SPDAT Housing location, SOAR, Peer Specialist Hospital list of 100 frequent utilizers 14 months, $14 million #1 on list $965,0000, #2 on list $648,000

53 Health Care Center for the Homeless How we started Attended CSH summit 2015 to interact, gain resources/contacts and knowledge of Housing First principles currently being utilized in other communities nationally. Site visits with local leaders in Houston, Salt Lake City. Participated in other trainings/workshops Collaborated with CoC partners to build/refine existing CES Hired full capacity: 1 Manager of Outreach and Case management, 6 case managers, 1 housing specialist, 2 peer support specialists, 1 program specialist, 1 SOAR disability specialist

54 Health Care Center for the Homeless How does it fit together? HCCH and the CoC supported by the local Regional Commission on Homelessness HCCH participates in the local Continuum of Care (CoC), partners with Homeless Services Network (HSN) agency that manages the Coordinated Entry System (CES) and HMIS for the region- the prioritized registry of homeless in the region. HCCH provides wraparound to clients referred into and back out to HCCH for permanent supportive housing. Partner w/ HSN who provides housing location and manages housing inventory in the region and referrals to other appropriate participating PSH programs in the CoC. HCCH operates Orange Blossom Family Health OBFH) provides medical/dental/mh & SA services to clients.

55 Health Care Center for the Homeless Support Data Includes: HMIS data on current homeless population numbers, PIT Counts, Surge counts, HUD eligibility Two hospital systems FUSE data supplied in partnership HCCH clinic data of FUSE homeless users Incarceration lists of FUSE users in two counties, as well as FUSE arrests of Downtown Orlando high visibility clients

56 Health Care Center for the Homeless Outcome Data Includes: 85% program participants remain housed for one year 80% will maintain or increase income 80% documented reduction in hospitalizations 80% demonstrate reduced incarcerations Additionally, HCCH is tracking impact of housing on health measures: A1c levels of housed clients with Dx of diabetes Hypertension Depression (PHQ-9 scores)

57 Health Care Center for the Homeless Table 1: Participant Demographics Mean Median Mode Minimum Maximum Age (in years) , 52, , 58 Male Female Gender 48(76.2%) 15(23.8%) Table 1. Participant numbers are based on the 63 participants with medical data available in the OBFH EHR.

58 Health Care Center for the Homeless Table 2: Patient Health Questionnaire (PHQ-9) Scores Mean SD 2-Tailed Significance Baseline PHQ-9 Score Subsequent PHQ-9 Score Table 2. Twenty-five participants had PHQ-9 scores recorded during at least one of their HCCH visits. For those patients, their baseline scores post-enrollment were averaged for the Baseline PHQ-9 Score.

59 SYSTOLIC BLOOD PRESSURE Health Care Center for the Homeless Table 3: Systolic Blood Pressures Visit 1 to Visit 6 Mean Standard Deviation 2-tailed Significance Systolic Blood Pressure Visit Systolic Blood Pressure Visit Mean Systolic Blood Pressures Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Table 3. Means of participant systolic blood pressures at visit 1 compared to systolic blood pressures at visit 6. N = 22

60 Recommendations Assess what other communities are doing Utilize data that is already being collected locally Encourage hospitals to use the ICD-10 code for homelessness (Z59.0) Consider tracking other social determinants of health Remember the small victories

61 Value = Outcomes

62 Q/A Discussion Q/A Discussion Have a question? Type into the Chat box. Enable Chat by clicking the icon in the top right corner.

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63 Next Steps Today s Recording & Slide Deck As soon as the recording is available, we will send you the slide deck and a link to the recording. Upcoming Webinars Stay Tuned! Survey When you log out of today s event, a pop-up window should appear displaying a survey about this webinar. We value your input! Resources & More Info on Upcoming Webinars:

64 About HRSA NCAs National Cooperative Agreements (NCAs) are national organizations that receive HRSA funds to help health centers and look-alikes meet program requirements and improve performance. They also support Health Center Program development and conduct national analyses around one of the following target audiences: Vulnerable populations, including those who frequently and inappropriately utilize health system resources Underserved Communities/Populations, such as the homeless, public housing residents, and migratory workers This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under cooperative agreement # U30CS26935, Training and Technical Assistance National Cooperative Agreement (NCA) for $325,000 with 0% of the total NCA project financed with non-federal sources, if any. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

65 Resources CSH, Health Outcomes & Data Measures: A Quick Guide for Health Center & Housing Partnerships: CSH, Profile on the Medical Respite Yakima Neighborhood Health Services & Circle the City: CSH, Profile on the Housing the First 100 Project Health Care Center for the Homeless, Orlando: content/uploads/2016/09/orlando-frequent-user-initiative- ProfileFINAL.pdf Additional Profiles available at CSH.org/hrsaTA

Integrated Care for the Chronically Homeless

Integrated Care for the Chronically Homeless Houston, TX January 2016 INITIATIVE OVERVIEW KEY FEATURES & INNOVATIONS 1 The Houston Integrated Care for the Chronically Homeless Initiative was born out of