R I C H A R D G F R A N K

D O N A L D M O U L D S

E M I L Y R O S E N O F F

G A V I N K E N N E D Y

Housing and Services: Models, Populations and Incentives

A Common Challenge

Promoting independence and self-determination for vulnerable populations

Protecting vulnerable people

Using public resources wisely

Vulnerable Populations

Frail older adults

People with major behavioral health problems (including severe and persistent mental illness)

Families in extreme poverty

People with intellectual disabilities

People with physical disabilities

Common Failures in Policy

1. Overemphasis on institutional care Compromises independence

Is costly

Creates pathologies

Can effectively coordinate and deliver array of services and housing

2. Reduction in reliance on institutions with inadequate investment in community support services

Homelessness

Social isolation

Victimization

Poor health outcomes

Organization of Issues

Housing models

Coordination approaches

Populations

Organization and financing of housing and services

Elements of Community Support

Safe and affordable place to live

Healthy food

Professional monitoring of health, safety and behavioral health

Supply of health care

Help with functional limitations (ADL; IADL)

Social and recreational activities

Recent Shared Conceptions of Housing

Supports aging in place; community integration; stability for low income families

Housing is distinct from services and viewed as permanent

Recognition that housing and services are complementary

What Has Worked in Housing

Single site—program participants only

Single site—mixed population of users (program participants a minority)

Scattered sites within a community

Clustered scattered sites—smaller buildings mostly occupied by program participants

Lessons about Trade-off

Cost of service delivery, coordination and monitoring

More concentration/lower cost

Community integration and independence

Less concentration more opportunities for integration

Risks of social isolation

Less concentration fewer people with shared experiences

Concerns about creating de facto institutions

Conceptions of Service Coordination

Identification of individual needs and preferences

Align services, needs and preferences

Types and quantity of the services

Mode and location of delivery

“Meet people where they are”

Coordination Mechanisms

Medical Human Services

Personal Assistance

Coping Skills

Service Coordination

X X

Case Managers X X

Interdisciplinary Team

X X X X

Organizational Arrangements that Work

Single agency—supplies full range of housing and services

Partnership models between housing focused and comprehensive services organizations

Lead agency model—responsible for arranging services from among multiple housing and service providers

Bottom up service organizer Naturally Occurring Retirement Communities (NORC)

Coping Skills

Community living makes high demands on coping skills compared to institutional life

New approaches to resource control Consumer direction/personal budgets

Coordination mechanisms support community living through training, support and augmentation of coping skills Skills training for SPMI/ID (ACT) Technology/environmental modification for older adults and

physically disabled Personal assistance with functional impairments

Observation

Housing and coordination models that work can fit a variety of service environments and populations

Matching coordination approaches, organizations, service intensity and populations is central challenge

Successful coordination mechanisms deploy organizational (inter-organizational) resources so that they yield saving by preventing costly/low quality outcomes

Failures have occurred due to mismatches of populations and services and mistakes in targeting

Populations

Frail Older Adults

SPMI Families in

Extreme Poverty

Help with ADLs X

Help with IADLs X X

Coping Skills X X X

Medical Care X X X

Addictions/Violence X X

Organization and Financing

Sources of Fragmentation

Vertical fragmentation—fiscal federalism

Terms of transfers affect program design and implementation at local level

Horizontal fragmentation

Boundary conditions between sector (e.g. health and social care) affect strategic behavior

Coordination/Housing Pay-offs

Coordinating an array of services aimed at people with complex needs that when not met result in costly/poor outcomes

Frail older adults with multiple chronic conditions and functional limitations (ADLs) Disproportionately in top 10% of spend>

People with SPMI that are with substance use problems and

repeated hospital stays (among highest cost group) Often chronically homeless

Families with incomes below 50% of poverty, single female heads, and domestic violence

Targeting is Critical

Cost effectiveness and savings are possible when housing and coordinated services are carefully targeted

Examples

Primary care teams at home for frail older adults with multiple chronic conditions that are home bound

Reduces hospital and emergency department use and yields savings of 5% to 25% (DeJonge et al, 2009)

ACT targeted at chronically homeless with a SPMI

Reduces days institutionalized yields savings ranging from 10% to 80% (centroid 20% to 40%)

Central Gov.

Institutions Nursing Homes

Health

Housing LTSS

Local Gov.

M

M

M

M

P M

P P

P M

Fragmentation in Financing

Examples

Nursing homes vs. aging in place

Diffusion of ACT for people with SPMI

Concluding Observations

Multiple strategies exist for effectively combining housing with services

Common principles of coordination apply across populations These involve adjusting intensity or service and targeting of resources to

where pay-offs are greatest

Targeting of housing with services is key for achieving savings and realizing cost-effective care

Fragmentation is a key obstacle to scaling of effective housing with services programs—nearly all OECD nations face this problem