FUSE Frequent User

Systems Engagement

Unconventional Wisdom

Ryan Moser

John Jay College

Prisoner Reentry Institute

October6, 2011

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Your

Story

Here

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20% of adult disabled patients subject to mandatory managed care account for 73% of costs

3% of patients accounting for 30% of all costs for adult disabled patients

Source and Image:

Billings, Dixon, Wennberg, et. all. 2006. Case Findings for Patients at Risk of Re-Hospitalization Development of an Algorithm to Identify High Risk Patients.

Costs of Healthcare

20 43130 175 194 218

362454

802

1,776

2,278

2,673

2,914

3,360

3,607

3,780

4,002

4,3844,481

4,706

0

500

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50001981

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Client "X" Cumulative DOC Days

Age 18

Age 31

Age 34

Age 37

Age 47

“Touching the Elephant in the

Dark”

Government agencies break down organic issues

Each agency has only a piece of the larger story

Solutions become piecemeal, focused on the part of

the problem the agency has tools to address

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The Institutional Circuit of Homelessness

and Crisis Service Systems

Indicates complex, co-occurring social, health and behavioral health problems

Reflects failure of mainstream systems of care

Demands more comprehensive intervention (supportive housing)

Detox

Emergency

Residential

Program

Jail

Shelter

Psychiatric

Hospital

Emergency

Room

Source: Urban Institute (2009)

Costs of Homelessness

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Assessed likelihood of top 10 characteristics differentiating the 10th decile

5 of those characteristics were related to criminal justice

Source and Image: Flaming, Matsunaga & Burns. 2010. Tools for Idenfitying High-Cost, High-Need Homless Persons, Economic Roundtable.

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20 43130 175 194 218

362454

802

1,776

2,278

2,673

2,914

3,360

3,607

3,780

4,002

4,3844,481

4,706

0

500

1000

1500

2000

2500

3000

3500

4000

4500

50001981

1982

1983

1984

1985

1986

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1991

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2000

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Client "X" Cumulative DOC Days

Age 18

Age 31

Age 34

Age 37

Age 47Cumulative DOC Days

Solution:

Frequent User

Systems Engagement

(FUSE) Initiative

FUSE Premise

Thousands of people with chronic health conditions cycle in

and out of crisis systems and homelessness - at great public

expense and with tremendous human consequences.

A multi-systemic response can succeed where a fractured

approach has failed.

Providing supportive housing to this group will improve life

outcomes for the tenants, make public resources more

efficient, and create cost avoidance.

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Interagency public-private collaboration

Demonstration initiative to test the premise of FUSE

Provide supportive housing with “front-loaded” intensive

case management services for frequent users of jail and

shelter

190 Apartments over two phases housing over 200 people

Frequent User Case Study

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DHS

DOC

Neither System

New York City FUSE

Implement Collaboration

Partner Role

NYC Departments of Correction

and Homeless Services

Data matching, program oversight, policy advocacy, service

enhancement funding, facilitate jail and shelter in- reach

NYC Department of Health and

Mental Hygiene

Services and operating funding and program oversight

CSH Program design, assembled and coordinated funding,

program oversight and troubleshooting, TA/training

NYC Housing Authority / Housing

Preservation and Development

Provide and administer Section 8 vouchers

JEHT Foundation / Langeloth

Foundation / OSI

Provided funding for service enhancements and evaluation

NYC OMB Program oversight

John Jay College / Columbia

University

Program evaluation

9 Non-Profit Housing and Service

Providers

Provide direct services and housing support (BCHS, BRC,

CAMBA, Common Ground, Community Access, Jericho

Project, Palladia, Pathways to Housing, and WPA)

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Cross-System Data Match

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NAME CLIENT_ID DOC_LOS DHS_LOS SHELTER DOCFacility

Page, J. 9862966231 45 98 Fortune RMSC

Moser, R. 9862966248 64 132 CSH EMTC

Jacobs, A. 2511910236 75 64 John Jay RMSC

Assertive In-Reach

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Courts

Jail/Prison

Street

Hospital

Detox

Alcohol/Drug Treatment

Shelter

Psychiatric Hospital

Supportive Housing

Section 8 Housing Choice

Vouchers (or State rental

assistance programs) + Mobile

Intensive Case Management

Services

Unit set-asides in new

supportive housing buildings or

existing supportive housing with

turnover

Providers trained in Motivational

Interviewing, navigating criminal

justice system, harm reduction,

recognizing “symptoms” of

incarceration

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Pillars and Steps of FUSE

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Data-Driven Problem-Solving

Cross-system data match to identify frequent users

Track implementation progress

Measure outcomes/impact and cost-effectiveness

Policy and Systems Reform

Convene interagency and multi-sector working

group

Troubleshoot barriers to housing placement and

retention

Enlist policymakers to bring FUSE to scale

Targeted Housing and Services

Create supportive housing and develop assertive recruitment process

Recruit and place clients into housing, and stabilize

with services

Expand model and house additional clients

John Jay College

Phase 1 Evaluation Outcomes

DOC DHS

FUSE Comparison FUSE Comparison

Average Days Pre 52.8 45.0 58.2 26.6

Average Days Post 25.0 36.0 4.6 7.0

Average Days Avoided 27.8 9.0 53.6 19.6

% Days Avoided 53% 20% 92% 74%

% Reduction Attributable to

FUSE 33% 18%

Days Reduced Attributable to

FUSE 17.2 10.7

Per Diem Jail/Shelter Cost $129 $68

Annual Cost Offset Per Person $3,586 $3,645

Adjusted Annual Cost Offset

Per Person $2,224 $729

Annual DOC & DHS Cost

Offset Per Person $7,231

TOTAL DOC & DHS Cost

Offsets for 190 Individuals $1,373,890

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One year later…

91% Housing Retention

92% Reduction in Shelter Use

53% Reduction in Jail Use

Jacobs, Fisher, & White.

John Jay College

Goal

Learn more about the

individual characteristics,

health, and social impacts

Examine longer-term

effects of the project

Understand patterns of

system involvement

Approach

In depth structured

interviews with historic

follow-back

2 year scope for

interviews and

administrative data

Trajectory analysis

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Columbia University

Phase 3 Evaluation Goals

Alcohol and Substance Abuse

1.5

15.4

0

11.5

32.8

9.2

0

5

10

15

20

25

30

35

40

Alcohol Abuse Drug Abuse IDU

Intervention Comparison

f

Substance Abuse Six months After Baseline*

Note: No differences in baseline regarding drug use patterns

Aidala, Bozack, McAllister, &Yamogida. Preliminary findings, do not quote or cite without express permission

Incarceration More often Before Homelessness

0

10

20

30

40

50

60

17 or younger

18-24 25-34 35-44 45-54 55-64

Num

ber

of Resp

ondents

(n)

Age

Age at First Episode of Homelessness and Incarceration

First Episode of Homelessness

First Episode of Incarceration

Aidala, Bozack, McAllister, &Yamogida. Preliminary findings, do not quote or cite without express permission

Institutional analysis suggests six patterns of combined jail & shelter use prior to intervention

Most typical patterns for each group

Group N % N 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

A 14 11.8%

B 27 22.7%

C 18 15.1%

D 23 19.3%

E 8 6.7%

F 29 24.4%

Totals 119 100.0%

Thirty-day Time Periods

• To read chart: — Orange means people in jail or in homeless shelter at least 1 day that 30 day period

— Cream: people not jailed/sheltered at all during that 30 day period

• Whatever was happening earlier in time, all were in jail/shelter at 12-18 months prior to baseline interview

• Patterns prior are quite varied early on

• Continuously institutionalized is modal pattern

• Patterns A & B together--not institutionalized in either setting at the start of period--are 1/3 of cases

Aidala, Bozack, McAllister, &Yamogida. Preliminary findings, do not quote or cite without express permission

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Implementing FUSE

Planning FUSE

FUSE Replication

“Institutional Creep”

Fractured

solutions to

complex

problems

result in the

expansion of

the wrong

systems.

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Institution Client

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or this…

Because

Housing

can look

like this

Atlantic Men’s Shelter

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Staten Island Inpatient Detox

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Bedford Hills

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Rikers Island

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We can do better!

For More Information

Ryan Moser

Managing Director

Corporation for Supportive Housing

ryan.moser@csh.org

www.csh.org

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