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 NYC Age 65+ Shelter population forecast
65-69 70-74 75-79 80+
8,000 Actual Forecast 7,000
6,000
5,000
4,000
3000
2,000
1,000
0
28
08 04 06 10 12 14 16 17 18 20 24
22
30
26
0
0 0 0 0 0 0 0 0 0 0 0
0
0
0
2
2 2 2 2 2 2 2 2 2 2 2
2
2 2
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 Estimating Costs for Each Intervention
Medical Need Cluster Cluster Cluster Cluster Shelter 4 4 3 2 1 Use Intervention Supports PSH PSH PSH Subsidy 1 + 2 Additional + Services 3 Cost Housing Annual $15,468 $15,468 $15,468 $4,795 $23,000 $11,500 $11,500 $1,650 Cost Service Annual $38,468 $26,968 $26,968 $6,444 Cost Annual Total 20 Estimating Service Cost Reductions
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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.
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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. Studies were weighted so those with stronger methodological rigor had larger weights and greater impact on the pooled average.
Scenario 2 Less 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 identified a significant reduction in health care costs.
22 Scenario 1 Scenario 2 A Range of Cost Category (More conservative) (Less conservative) Potential Service Cost Inpatient medical -18% -33% Reductions Emergency Department -6% -45% Outpatient medical -6% -45% Outpatient behavioral health 48% -29% Inpatient behavioral health -35% -56% Nursing home -42% -90% Shelter -71% -71%
23 Cost Reduction Possibilities by Age Group: LA County Average per Person Per Year
$12,000 $11,346 $10,668 $10,000 $9,834 $8,869
$8,000 $6,969 $6,978 $6,570 Age 55-59 $5,951 $6,000 $5,498 Age 60-64 Age 65-69 $4,000 Age 70+
$2,000
$- More Conservative Less Conservative Cost Reduction Scenarios Housing Intervention Cost
24 Cost Reduction Possibilities in NYC Average Per Person Per Year
$14,000 $13,215
$12,000 $11,033
$10,000 $9,171
$8,000
$6,000
$4,000
$2,000
$0 More Conservative Less Conservative Service Cost Reductions Housing Intervention Cost
25 Cost Reduction Possibilities in Boston Average Per Person Per Year
$10,000 $9,073 $9,052 $9,000 $8,000 $7,000 $6,000 $4,946 $5,000 $4,000 $3,000 $2,000 $1,000 $0 More Conservative Less Conservative
Service Cost Reductions Housing Intervention Cost
26 Annualized Average Projected Costs & Potential Cost Reductions (in millions of $) Net Offsets (Service Cost Service Costs Interventio Average Service Cost Reductions - Return Per without an Intervention n Costs Reductions Intervention Costs) Dollar Spent
New York City $408 $157 $177 $20 1.13 Boston* $67 $39 $30 ($9) 0.77 LA County $621 $241 $274 $33 1.14
* Boston service costs and cost reductions exclude Medicare-reimbursed services. A forthcoming analysis estimating Medicare costs suggests that an intervention would be break-even or provide net savings
27 Could Housing Solutions be Funded by Resultant Service Cost Reductions? Yes
28 National Projections (with cautions)
250,000
200,000
150,000
100,000
50,000
0 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 55-64 65+
29 Key Stakeholders U.S. HUD & VA U.S. DHHS – CMS State Medicaid Regulatory Agencies Medicaid Managed Care Organizations Hospitals & nursing homes Homeless Service Providers (CoC’s) Housing Authorities
Local Area Agencies on Aging
30 • How to advance fund the housing “investment”?
Policy • MCOs as rapid rehousing funder under a critical time Considerations intervention model?
• Start now targeting hospital and ER discharges and nursing home diversion?
• Ramp up over time, starting with 65+ or 62+ to gain momentum and develop policies and procedures?
• Federal challenge grant program to states for pilots?
• Local/state pay for shallow subsidies as alternative to shelter, and sunsetting over time?
• Hospitals as key local leaders and conveners? Dissuade from “medical respite” push?
31