Blog: Homelessness Ends Here

The following client case study is courtesy of Dr. Fred Osher, Psychiatrist and Director of Health Systems and Services Policy at the Council of State Governments, who, in addition to his prominent role in national policy, continues to see clients at the Baltimore Health Care for the Homeless.  

Mr. R. is a 53-year old man who, like many homeless adults, had grown up in various unstable housing situations.  He left school in 10th grade to “run the streets,” and began selling and using heroin and cocaine.  He spent several years cycling in and out of jail/prison until he picked up enough charges to warrant long term incarceration.  After his discharge from a Maryland Department of Corrections facility, Mr. R. became homeless once again.  Or more accurately, he became a regular customer of a number of different emergency service settings including homeless shelters, jails, transitional housing, drug treatment and detox facilities, psychiatric centers, emergency rooms, and hospitals. 

Individuals like Mr. R. live on what medical anthropologist Kim Hopper has termed “the institutional circuit,” bouncing from one institution or emergency service system to another, staying in these settings for only days or weeks at a stint, all the while experiencing worsening behavioral and physical health conditions.   They are living examples of the piecemeal and patchwork systems of care that exist in this country, and underscore our nation’s shameful paradox of being the country that spends the most money on health care with the poorest results. 

Over the past 20 years, our nation has seen the creation of an entire generation of frequent users of public services like Mr. R., leading in no small part to the state budget crises we now see in nearly every state in the country.  Indeed, while Medicaid and corrections comprise the largest and steadily growing state budget expenditure items for most states, emerging evidence is showing that many of these expenditures are avoidable.  A recent study in New York State found that only a small subset (roughly 20%) of Medicaid enrollees consume the majority (73%) of the publicly funded services, and that the majority of these enrollees are individuals who repeatedly “use” the same services (i.e. are hospitalized) with little to no improvements to their conditions.

In recent years, many communities around the country have been experimenting with ways to put an end to the institutional circuit for these frequent users of public systems, and with one innovative stone, kill the two birds of promoting individual stability and restoring fiscal sanity.

One set of communities focused on frequent visitors of emergency departments and hospital inpatient wards.  Another focused on individuals with behavioral health problems who were being admitted to local jails and correctional facilities every other week.  (A few recognized that many of these individuals were one and the same.)  Approaching the problem from different directions, these communities nonetheless converged upon the same solution to their public health, public safety, and budgetary crises: targeted, assertive, and flexible case management paired with deeply subsidized affordable housing.  In other words, Permanent Supportive Housing. 

The Corporation for Supportive Housing (CSH) has played a central role in designing, launching, and evaluating these models.  In Northern California, CSH worked with six counties to launch the Frequent Users of Health Services Initiative (FUHSI), a demonstration program that wrapped intensive case management along with coordinated health services (what today is being commonly referred to as a “medical home” model) around frequent users of emergency departments and inpatient hospital beds.  Several counties in the region recognized that an overwhelming majority of these frequent users were homeless and coupled housing subsidies and housing assistance with their service supports.  The demonstration was an unqualified success.  In two years, the program reduced emergency department visits among frequent users by 61% and inpatient hospitalizations by 64% on average, resulting in an annualized average cost avoidance of almost $39,000 per person.

In other parts of the country, CSH created and implemented the Frequent User Service Enhancement (FUSE) program, which uses permanent supportive housing available to break the cycle of incarceration and homelessness among frequent users of jails and homeless shelters.  Starting in New York City, CSH worked with City officials to 1) conduct a data match to identify individuals who were frequently cycling between jails and shelters at a high cost to the City; 2) assembled Section 8 Housing Choice Vouchers, set-asides within existing supportive housing, supportive services, and philanthropic resources to create permanent supportive housing; 3) train supportive housing providers to conduct in-reach into jails, shelters, and other emergency service setting to recruit participants, and 4) place these frequent user individuals into supportive housing, and break the cycle of homelessness and incarceration for over 100 frequent flyers of the notorious Rikers Island and New York City shelter system. 

FUSE is now being replicated by Cook County (IL), Hennepin County (MN), Connecticut, the District of Columbia, and Philadelphia.  Results from the New York City model show the program’s tremendous promise for changing lives and reducing costs.  In just two years after placement into supportive housing, the frequent users participating in the program in New York City had a 92% housing retention rate, a 53% reduction in days spent in jail, and a 92% reduction in days spent in shelter.  Further analysis examined the cost avoidance associated with these outcomes:

In October 2008, CSH brought together these communities and others at our ‘Frequent Users Forum’ to share findings, challenges, and lessons around how to leverage housing and services to stop the revolving door to emergency rooms, hospitalizations, detox visits, jail admissions, etc.  Providers, practitioners, and policymakers from San Diego to Boston, Seattle to Florida and many places in between were gathered.  They were surprised to see how, working in isolation from one another, they largely ended up with the same kinds of strategies: using and matching administrative data across systems to identify frequent users, structuring flexible and interdisciplinary case management teams, employing services approaches that focus on engagement and relationship building to overcome service resistance, and creatively blending public resources like Housing Choice Vouchers, Medicaid, mental health grant dollars, and philanthropic support.

A year later, CSH is releasing two versions of its report summarizing the forum’s proceedings, entitled Frequent Users of Public Systems: Ending the Institutional Circuit - Changing Systems to Change Lives.  This report includes a statement of the policy problem that frequent users represent, profiles of the housing and services programs featured at the forum, findings from the various program evaluations, and a call to action for policymakers and practitioners alike.

CSH will be formally releasing these reports via teleconference on Wednesday, January 27, 2010 at 2-3pm Eastern / 1-2pm Central / Noon-1pm Mountain / 11am-Noon Pacific.  On this teleconference, we will be providing an overview of our report, and will feature presentations by Brenda Goldstein of Lifelong Medical Center in Oakland, California and Mikkel Beckman of St. Stephen’s Human Services in Minneapolis, Minnesota.  Brenda will discuss her experience providing services to frequent users of health services through the Alameda County FUHSI project, and Mikkel will discuss his experiences with providing supportive housing to frequent users of corrections and homeless services in Hennepin County, Minnesota. 

To register for this teleconference, go to www.csh.org/hottopics.

CSH is now looking to take FUHSI, FUSE, and similar models to scale nationally.  Our vision is to launch a permanent supportive housing initiative targeted at frequent users of public services in every jurisdiction with high rates of chronic homelessness, overcrowded emergency rooms, and jails filled with people with behavioral health problems.  For more information on how to solve the problem of frequent users in your community, contact:

Richard Cho
Director, Innovations and Research
Richard.cho@csh.org

Richard Cho is director of the Corporation for Supportive Housing's Innovations and Research Unit. Richard has been with CSH over eight years and has been "innovating" the entire time, from figuring out how supportive housing can benefit those re-entering communities from the criminal justice system to designing programs to serve a multitude of populations.