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The Emerging Crisis of Aged Homelessness: Could Housing Solutions Be Funded by Avoidance of Excess Shelter, Hospital, and Nursing Home Costs?

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The Emerging Crisis of Aged Homelessness: Could Housing Solutions Be Funded by Avoidance of Excess Shelter, Hospital, and Nursing Home Costs? The Emerging Crisis of 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 Acknowledgements 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 2 Agenda Projections of the Aging Homeless Population for Presentation Understanding Healthcare Service Usage of Older Homeless Adults Identifying Subgroups by Shelter & Healthcare Service Use Identifying Potential Cost Offsets Considering Stakeholders & Possible Next Steps 3 Homelessness, A Birth Cohort Phenomenon Single Adult Male Shelter Users, United States Sheltered Homeless % Single Adult Males Aged 46-54 12 Population 10 1990 1 in 8 in 1990 2000 1 in 5 in 2000 8 2010 1 in 3 in 2010 Homeless 6 Male Male 4 Adult Adult 2 Single Single 0 of of % 4 Forecasting Change in 65+ Homeless Population 3.0 2017 to 2.5 Relative Relative 2.0 Growth Growth 1.5 Population Population 1.0 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Los Angeles Boston New York City 5 NYC Age 50+ Shelter population forecast 50-54 55-59 60-64 65-69 70+ 25,000 Actual Forecast 20,000 15,000 10,000 5,000 0 17 08 12 04 06 10 14 20 22 24 26 28 30 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2016 2018 2 2 2 2 2 2 2 2 2 2 2 2 6 3000 4,000 5,000 6,000 7,000 8 1,000 2,000 , 0 forecast NYC 00 0 2004 Age Age 2006 2008 65+ 2010 Shelter 2012 6 5 - 2014 69 population Actual 7 2016 0 - 74 2017 Fo r 2018 7 ecast 5 - 79 2020 8 0 + 2022 2024 2026 2028 2030 7 Change in Shelter Population for 5-Year Birth Cohorts: New York City, 2005 - 2030 6,000 Shelter 5,000 in 4,000 adults adults of of 3,000 2,000 Number Number 1,000 0 1945-49 1950-54 1955-59 1960-64 2005 2010 2015 2020 2025 2030 8 Aging Homelessness Trends Across U.S 9 Examining Shelter, Healthcare, and Nursing Home Use & Costs of Older Homeless Adults Data Boston Sources Shelter: City of Boston HMIS Health care: MassHealth Medicaid Claims Los Angeles Shelter: Los Angeles Homeless Services Authority & 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) 10 Average Annual Per Person Costs by Age: New York City $30,000 $28,457 $27,314 $25,159 $25,000 $24,455 $20,000 Nursing Home $15,000 Inpatient Care ED Visit $10,000 Shelter $5,000 $0 55-59 60-64 65-69 70+ 11 Nursing Home Use by Age: LA County 20 18 Homes 16 14 12 Nursing 10 in in 8 Days Days 6 of of # 4 2 0 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 Age 12 Projecting Total Costs through 2030: New York City $500 $450 $ $400 of $350 millions millions $300 $250 Year, Year, Per Per $200 $150 Costs Costs $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 13 Segmenting into Subgroups Cluster Analysis: A tool for grouping observations based on to Assess Potential Housing similarities and dissimilarities & Service Needs Clusters were created based on a small set of variables, and validity was assessed through other variables of service use and medical acuity 14 Cluster 4 Results High 2.6% Cluster 1 Cluster 2 Cluster 3 Moderate 84.6% 11.4% 1.4% Need Analysis Low Medical Low Moderate High Very High Shelter Use Subgroup Subgroup Gagne Inpatient Shelter Days Comorbidity Hospital Days Cluster Description Cluster Share 2009 - 2015 Index 2011 - 2015 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 15 Use Nursing Health Total Shelter Inpatient ED Home Shelter Services Services Days Days Visits Days Cost Cost 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 Healthcare Cluster 3 329 3 1 3 $38,638 $10,281 $48,919 & Cluster 4 9 51 10 32 $1,075 $175,437 $176,494 Shelter Shelter 4 Annualized Annualized 1 2 3 Need Medical Shelter Use Subgroups: Subgroups: 16 Envisioning a Continuum of Potential Interventions 17 4 1 2 3 Need Medical Shelter Use Subgroup 1: Expect homelessness to self-resolve for one-third of this cluster, as Progressive Engagement 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 19 4 1 2 3 Need Medical Shelter Use Subgroups 2, 3, and 4: Long-term housing + supportive services for chronically homeless Permanent Supportive populations Housing 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 19 Annual Annual Total Housing Service Annual Intervention Cost Cost Cost $6,444 Intervention Cluster 1 Subsidy + Services $4,795 $1,650 Cluster 2 PSH $15,468 $11,500 $26,968 Cluster 3 PSH $15,468 $11,500 $26,968 Each Cluster 4 PSH + Additional $15,468 $23,000 $38,468 for Supports 4 1 2 3 Estimating Costs Estimating Need Medical Shelter Use 20 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 on 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 Moving15. Wright IntoBJ, SupportiveVartanian Housing.KB, Li H Health-F, Royal Aff.N,2016;35(1):20Matson JK. Formerly-27. Homeless People Had Lower Overall Health Care Expenditures After 22 Service Cost Scenario 1 Reduction Scenarios 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.
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