Download pdf - Integrated Care for the Chronically Homeless - CSH...2 History HUD Target Population Approach Participants are identified through Houston’s Coordinated Access process. They enter

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✦ TeamApproach:Amultidisciplinarycareteamisassembledtoprovideholisticservicestotheindividuals.Thisteamincludesprimarycareproviders,behavioralhealthproviders,clinicalcasemanagers,medicalcasemanagers,communityhealthworkers,housingproviders,andgovernmentagenciesprovidingoversight.

✦ TeamMeetings:Theinterdisciplinaryteamcomestogetherfivedaysaweektodiscussconsumerneedsandworkthroughanypotentialwaystoaddresstheseneeds.

✦ CommunityHealthWorkers(CHW):CHWsplayamajorroleinsupportingtheindividualwiththelogisticalaspectsofmanagingtheirphysicalhealth,behavioralhealth,andsocialneeds.Theymaygotoappointments,coordinatethelogisticsofcare,andreinforcetreatmentadherence.

✦ CommunityCollaboration:TheHoustoncommunityhascreatedahighlycollaborativesystemthatshowsinvestmentbeyondintegrationofcare.Partnersfromdifferentsectorsworkcloselytoovercomebarriersandcreateastrategythatwillbestservetheconsumer.

✦ ConnectiontoHousing:Clinicalcasemanagershelpindividualsthroughtheprioritizationprocesstoreceivehousing.Theirapproachemphasizestheroleofhousinginstabilizinghealthcare.

✦ HousingVouchers&RentalSubsidies:ThelocalContinuumofCareandHousingAuthorityprioritizedinitiativeparticipantsforprojectbasedhousingvouchers.RentalsubsidiesareprovidedthroughtheHoustonHousingAuthority.

✦ TheHoustonIntegratedCarefortheChronicallyHomelessInitiativewasbornoutoftheTexas1115MedicaidWaiverprogramandtheCityofHoustonHealthandHumanServicesDepartment.The1115Waiverincentivizedthedevelopmentofinnovativecaredeliverymodelsandcreatednewfundingpoolstoensureprovidersarereimbursedforprovidingqualitycaretovulnerableindividuals.Thenewcaredeliverymodelsaredesignedtomeetthegoalsofimprovedaccess,increasedcoordinationofcare,improvedhealthstatus,andreducedcosts.

✦ HealthcarefortheHomeless-Houston(HHH)waschosenasoneoftheleadHealthCentersfortheHoustonIntegratedCarefortheChronicallyHomelessinitiative,whichisajointeffortbetweenthehealthandaffordablehousingsectors.HHHprovideson-sitewrap-aroundservicesinpartnershipwithSEARCHHomelessServices(homelessserviceproviderintheGreaterHoustoncommunity),whichprovidesclinicalcasemanagement,andNewHopeHousing,Inc.providinghigh-qualitypermanent,affordablehousing.

✦ Thisprogramtargetsindividualswhoareexperiencingchronichomelessnessandhaveaminimumof3emergencydepartmentvisitsovertwoyearswiththegoaltoimprovehealthstatus,qualityofcare,andhousingstabilityfortheseindividuals.

✦ Sofar,theparticipantshaveshownimprovementinhealthfunctioninganddepressionscores,andareductioninemergencydepartment(ED)useandunnecessaryhospitalizations.

✦ Challenges:Aswithanynewprogram,thereweresomechallengesimplementingtheprogramincludinglearningtoworkacrosssectorsandadjustingoperationalprocesses.Withinvestmentandflexibility,theseissueswereaddressedandtheprogramwasstrengthened.

✦ Opportunities:Asupportivecommunityinfrastructurethatencouragescollaboration,experiencesworkingwithvulnerablepopulations,andopportunitiesthatcameoutofhealthreform,suchasthe1115MedicaidWaiver,encouragedthedevelopmentofthisprogram.

INITIATIVEOVERVIEW

Integrated Care for the Chronically Homeless

Houston, TX | January 2016

KEYFEATURES&INNOVATIONS

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History

Target Population Approach

ParticipantsareidentifiedthroughHouston’sCoordinatedAccessprocess.TheyenterthissystembycompletingtheVulnerabilityIndex(VI)assessmentatoneofthedesignatedassessmenthubs,thecallincenter,orduringaninteractionwithanoutreachteam.Individualswhoareeligibleareprioritizedfortheprogrambasedontheirvulnerabilityandneed.Individualsarethenreferredtothehealthcenterforanassessmentbytheclinicalteam.HealthcarefortheHomeless-Houston(HHH)purchasedtheirelectronichealthrecordthroughthecountypublichealthsystem,whichgivesthemaccesstoHarrisCounty’shealthrecordsandallowsthemtocheckthenumberofemergencydepartment(ED)visitsfornewandestablishedparticipants.Whentheindividualmovesintohousing,thehealthcentercontinuestoprovidewrap-aroundservicesthroughanon-sitecareteamandoffersadditionalservicesoff-site.Theteamconductsregularstaffmeetings-includingmembersofNewHopeHousing’sresidentservicesandpropertymanagementteam-todiscusshealthinformationaswellasotherclinicalandsocialelementsintheindividual’slifetoensuretheyreceivehigh-qualitycarethatmeetstheirneeds.

Integrated Care for the Chronically Homeless: Houston, TX

INITIATIVEDETAILS

CommunityHealthWorkers:Alignphysicalandbehavioralhealthwithsocialneeds.Theymayattendappointments,

reinforcetreatmentadherenceandassistwiththe

logisticsofmedicalcare.

RN

ClinicalCaseManager

CommunityHealthWorker

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AssessmentbyClinicalTeam

ClinicalTeam:PrimaryCareProvider,BehavioralHealthProvider,MedicalCaseManager,ClinicalCaseManager,

andCommunityHealthWorker

CoordinatedAccessSystem

CallCenter

AssessmentHub

OutreachTeam

PrioritizedbasedonVIScore

3ormoreemergencydepartmentvisitsintwoyears

IdentifiedandPrioritizedthroughCoordinatedAccess

ChronicallyHomelessHUDDefinition

*HUDisimplementinganewdefinitionofChronicHomelessnesseffectiveJanuary16,2016.

2012HealthcarefortheHomeless-HoustonHospitalInreachProjectincorporatedtwocommunityhealthworkerswhichallowedtheagencytovaluetheworkofCHWsandexpandto

have9CHWsinvariousprograms.

2008TheseedsofsupportivehousingaresownwhenNewHopeHousingand

SEARCHattendaCSHtraininginstitute.

2010HealthcarefortheHomeless-Houstonstudy

foundthathomelesspatientshavehigher

hospitalreadmissionratesthandomicilepatients.

TheTexas1115MedicaidWaiver

approvedinlate2011creatednewfundingpoolsandincentivized

innovativecaredeliverymodels.

Houstonwasnameda

HUDPriorityCommunity

in2011.

In2012,theHouston

ContinuumofCareadoptedan

updatedStrategicPlantoEnd

Homelessness

Citygoaltohouse2,500peopleaspartofthisinitiativewith

HHHtakingon200individualsfromthisproject.NewHope

Housing,Inc.hascommittedtohousing200individuals.

HoustonMayor’sOfficeandCityHealthDepartmentdevelopedajointprojectthatpairedhealthcentersandhousing.It

includedtheHealthDepartment,HoustonHousingAuthority,andtheCityHousingDepartment.HealthcarefortheHomeless-Houstonwaschosenasaleadhealthcenter.NewHopeHousinghasbeentheleadingproviderofaffordablehousingunits.TheprojectcontractswithSEARCHHomelessServicestoprovide

clinicalcasemanagement.

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Goals: The1115MedicaidWaiverProgramwillserve2,500chronicallyhomelessindividuals.200willbeservedbythiscareteam.

Outcomes

Forinformationonavailablescreeningtools,visittheSAMHSA-HRSACenterforIntegratedHealthSolutionsordownloadthePHQ-9athttp://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf.FormoreinformationontheSF-36,visithttp://www.rand.org/health/surveys_tools/mos/mos_core_36item.html.

OUTCOMES


WhilethereisanexpectedincreaseinappropriateEDvisitsandhospitalizations(medically

necessaryvisits)ashealthconditionsarestabilized,thereisanoticeabledecreaseininappropriate(non-

emergency)EDuse.

EDUse

Attheendofthefirstyear,participantsshowedameaningfuldifferenceinhealthfunctionalstatusonbothphysicalandmentalhealth,withagreaterimprovementinmentalhealth

status.

SF-36

Withinoneyearofprogramstart-up,participantsare

showingclinicallysignificantresponseinoveralldepressionscoresas

measuredbythePHQ-9.

PHQ-9

200chronicallyhomelessindividualswillbeplacedintosupportivehousingandconnectedtointegratedcareteamwithprovidersfromHHH,SEARCHHomelessServices,andNewHopeHousing,Inc.toachievethefollowinggoals:

Reductioninnon-essentialEDvisitsandhospitalstays

ImprovedHealthStatusasmeasuredbytheSF-63and

PHQ-9StabilizationinHousing

QualityImprovementIncreasedincomethroughSSI/SSDI,Outreach,Access&RecoverytrainedCHWs

HousingRetention

IncreasedSupportiveServicesandProgram

Participation

ImprovedQualityofLife

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Challenges ✦ LearningtoUnderstandEachOther:HealthCenters,socialserviceproviders,andhousingprovidersallspeakdifferent

languagesandareregulatedbydifferentgoverningbodies,whichcanaddstraintotherelationshipbetweenproviders.InHouston,SEARCHHomelessServicesclinicalcasemanagersweregivenaccesstoparticipant’smedicalrecordsbuttherewasasteeplearningcurvetounderstandingthelanguageandcoding.Attimes,HHHclinicalstafffeltisolatedbecausetheirprimaryfocus(primarycare)differsfromthatoftheotherorganizations(casemanagement)andtheyareaccountabletoadifferentsetofregulations(statemedicallawsandHRSAprogramrequirements),andthereforehaddifferentpriorities.Ittakestime,investment,andworkingasateamtoovercomeconflictsthatmayarisebytryingtonavigatethedifferentsystemstoachievetheoverallgoal.

✦ ChaoticNatureofaStart-upProgram:Inastart-upprogram,suchasthisone,thereistheconstantneedtoreevaluateandsometimesrestructure,processesandrolestoensurethattheprogramisaseffectiveaspossible.Thiscanbestressfulforstaffastheprogramcontinuestoevolve.

• StaffRoles:Astheprogramdevelopsandexpands,staffrolesmaychangetomeetconsumerneeds.ThisprogramfoundthatCHWsneededtoallowmoretimeforlogistics,suchasschedulingappointments,andaspecificfocusonhealth-relatedmatters,includingworkingwithparticipantstoprepareforsurgery.

• AddressingandAdjustingCurrentPractices:Withtheadditionofanewprogram,currentpracticesofparticipatingorganizationsmayhavetobeupdatedtobetterserveapatientpopulationthathasdifferentneeds.Forexample,HealthcarefortheHomeless-Houstonfoundthattheyneededtoreconsidertheirclinicalmodelthathadpreviouslyfocusedonepisodiccarethroughnecessitybutnowhastheopportunitytofocusoncontinuityofcare.

✦ ExpectationsandResponsibilities:Alongwithlearningtounderstandthelanguageandprioritiesofeachorganization,theremaybeconflictingideasofwhataretheresponsibilitiesofeachagency.Forexample,clinicalprovidersandhousingprovidersdefinecasemanagementdifferently,makingitnecessarytoreconcilewhatresponsibilitieswillfallontheclinicalcasemanager(briefinterventions,housingnavigation,andassessments)andwhatwillbethehousingprovider’sresponsibility(supplementalhousingsupports).

✦ DealingwithIncreasedNumberofCrises:WhileHealthcarefortheHomeless-Houstonhasalwaysservedvulnerablepopulations,theshiftinfocusforthisprojectbroughtwithitanincreasednumberofhealthcrisesandchronicillnesses.Theyhadtodevelopprocessestohandlethischangeaswellassupportthestafftopreventburnout.

✦ Technology:Whenserviceprovidersareworkingremotely,thenetworksdidnothavethecapacitytomanageadditionalusertraffic.Providershadtohavepersonaltechnologyhotspotsathousingsitesinordertousetheirreportingsoftware.

Opportunities ✦ 1115Waiver:The1115MedicaidWaiverinTexasprovidedanopportunitytodevelopthecollaborativeproject.

✦ CommunityPlan:Thedevelopmentofacommunityplantoaddresshomelessnessprovidedabackdroptoencouragemyriadorganizationalparticipationintheprogram.ThePlanalsoestablishedPermanentSupportiveHousingandtheHousingFirstmodelasapriorityandensurethathousingvoucherswereavailableforprojectparticipants.

✦ ExperiencewithOtherProjects:HealthcarefortheHomeless-Houston’sexperiencewithanotherprogramtargetingchronicallyhomelessindividualsexitingthecriminaljusticesystemwithamentalhealthdiagnosisallowedthemabasisforprogramdevelopmentandhelpedtoinformstaffexperiences.


CHALLENGESANDOPPORTUNITIES

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Health Center: Healthcare for the Homeless - Houston (HHH) Roles:✦ On-sitePrimaryCare✦ MotivationalInterviewing✦ BriefInterventionsincludingCognitiveBehavioralTherapy✦ GroupTherapy✦ PrimaryCareBehavioralHealthConsultationlocatedattheHealthCenter

• TheHealthCenterhasachievedlevel6integrationthroughtheabilitytoaddBehavioralHealthConsultants.✦ SubstanceUseandBehavioralHealthCounselingavailableattheHealthCenter✦ CommunityHealthWorkerstoassisttheconsumerinmanagingtheirhealthneeds.

Homeless Services Provider: SEARCH Homeless Services Roles:✦ ClinicalCaseManagementincludingmorein-depthMotivationalInterviewingandCognitiveBehavioralTherapy✦ WorkcloselywithCoordinatedAccess✦ AssistinnavigationbetweenbeingidentifiedinCoordinatedAccessasapotentialprogramparticipantandgettingintohousing✦ Conductinitialandfollow-upassessmentinthelocalHomelessManagementInformationSystem(HMIS)

• Follow-upassessmentsarecompletedeverysixmonths

Housing Provider: New Hope Housing, Inc. Roles:

✦ PropertyManagement• Thehousingproviderhasdedicatednearly450unitsoftheirportfoliotopermanentsupportivehousing.

✦ Supplementalsupportiveservicestoresidents✦ Coordinationwithserviceproviders✦ Institutedahousingfirstmodel


INITIATIVEPARTNERS

OPERATIONALEXPERIENCES&LESSONS

✦ UsingAssessmentScores:StaffhasbeenabletouseSF-36andPHQ-9scoresasateachingmomentbothonindividualandaggregatepopulationlevels.Inworkingwithconsumers,theycanusethesescorestoprovidefeedbackandusethemaspartofbriefintervention,inhopesofimprovingthescoreovertime.Onthepopulationlevel,staffisabletolookatlargerchangesoveralltoidentifysuccessesandchallenges.

✦ AdvancedAssessment:Itiseasiertoassessindividualsintheclinicpriortoenrollingthemintothehousingprogramastotheirabilitytoliveindependently.Insomecases,therehavebeenindividualswhohaveneededahigherlevelofcarethanisfeasibletoprovideinsupportivehousing.Thiscouldbeaphysicalhealthconditionthatneedssupervisiontomaintainstability.Inthiscase,individualsareconnectedtoamoreappropriatehousingoptionthatmeetstheirneedsthroughtheContinuumofCare.

✦ AcuityofPhysicalHealthConditions:TheHealthCenterwassurprisedbytheacuityofthehealthneeds.Basedontheliterature,theyhadexpectedbehavioralhealthneedstospikeuponenteringhousing,buttheywerenotpreparedfortheacuityofphysicalhealth.Whentheprogrambegan,stafffeltasthoughtheyweremovingfromcrisistocrisisandexperiencedadeathwithinthefirsttwoweeks.Theyhadtoadapttoprovidethecarepatientsneededandsupportfortheirstaff.

✦ OrganizationalPolicyChanges:Thehousingproviderfoundthatbynatureofworkingwithamorevulnerablepopulation,theyhadtoaddresssomeoftheirpolicies.Theyhaveazerotolerancefightingpolicyformostoftheirhousingunitsbuthadtoadaptamoretolerantpolicytoensurehousingstabilityforprogramparticipants.Inaddition,NewHopeHousingadoptedahousingfirstmodelforthisprogram,allowingindividualswhoareactivelyusingsubstancestoobtainandremaininhousing.

✦ SteppingoutoftheOrganizationalComfortZone:Thehousingproviderfoundthatjoininginacollaborativepartnershiprequiredthattheorganizationopenupandisvulnerableinordertobepartofthelargerconversation.Theyhadtomovepastnegativeexperienceswithattemptedproviderpartnershipsandworktodevelopastrongerrelationshipwithnewpartners.

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Funding Sources Start-upFundingOpportunities:CurrentFunding:

PotentialFundingOpportunities:

Costs Savings Costsavingshavebeenobservedbutarenotyetquantifiableasthisisthefirstyearoftheprogram.

Program Costs

FINANCES


Roughly90%ofprogramcoststotheHealthCenterandSEARCHareforstafftime

Remaining10%includes:StaffTrainingandEducationPharmaceuticalsTransportationSuppliesITCostsAdministrativeTimeSF-36costs

Transportationincludescostforbothstaffmileageandpatienttransportationcosts.

ITCostsincludelaptops,hotspotsandmobilephonesneededtoprovidecareawayfromthehealthcenter.

1115Waiver:TheMedicaid1115WaivercreatedtheDeliverySystemReformIncentivePayment(DSRIP).ProvidersareabletoreceiveDSRIPpaymentsiftheyparticipateinanapprovedinnovativecaredeliverymodelandmeetcertainoutcomemeasures.

ThehealthcenterisintalkswiththelocalMedicaidManagedCareOrganizations(MCOs)aboutthepossibilityofreceivingpaymentforcarecoordination.

ThehealthcenterwasabletoemploytheirfirsttwoCHWsthroughapartnershipwiththeNationalHealthCarefortheHomelessCouncilaspartofaCMSHealthCareInnovationAward.

MedicaidBilling:ThehealthcenterbillsforservicesthatarecoveredbyMedicaid.However,sinceTexasisanon-expansion

state,mostservicesandindividualsarenotcovered.

HRSAHealthCenterProgramFunding:HealthCenterprogrambasefundingisalargeportionof

theHealthCenter’soverallfundingandisusedtofinancestaffand

operations.

HousingVouchers:TheHoustonHousing

AuthorityprioritizedProjectBasedHousingVouchersforprogram

participants.

Grants&PrivateFunding:Aportionofcasemanagement

serviceswereprovidedthroughvariousoutside

fundingsources.

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CSHtransformshowcommunitiesusehousingsolutionstoimprovethelivesofthemostvulnerablepeople.Weoffercapital,expertise,informationandinnovationthatallowourpartnerstousesupportivehousingtoachievestability,strengthandsuccessforthepeopleinmostneed.CSHblendsover20yearsofexperienceanddedicationwithapracticalandentrepreneurialspirit,makingusthesourceforhousingsolutions.CSHisanindustryleaderwithnationalinfluenceanddeepconnectionsinagrowingnumberoflocalcommunities.WeareheadquarteredinNewYorkCitywithstaffstationedinmorethan20locationsaroundthecountry.Visitcsh.orgtolearnhowCSHhasandcanmakeadifferencewhereyoulive.

ABOUTCSH

TheNationalHealthCarefortheHomelessCouncilisanetworkofdoctors,nurses,socialworkers,patients,andadvocateswhosharethemissiontoeliminatehomelessness.Since1986wehavebeentheleadingorganizationtocallforcomprehensivehealthcareandsecurehousingforall.Weproduceleadingresearchinthefieldandprovidethehighestleveloftrainingandresourcesrelatedtocareforpersonsexperiencinghomelessness.Wecollaboratewithgovernmentagenciesandprivateinstitutionsinordertosolvecomplexproblemsassociatedwithhomelessness.Additionally,weprovidesupporttopublichealthcentersandHealthCarefortheHomelessprogramsinall50states.Visitnhchc.orgtolearnmore.

ABOUTNHCHC

AllphotosdepictstafforconsumersreceivingservicesfromHealthCarefortheHomeless-Houston,NewHopeHousing,Inc.orSEARCHHomelessServices.

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“ThisprojectwassupportedbytheHealthResourcesandServicesAdministration(HRSA)oftheU.S.DepartmentofHealthandHumanServices(HHS)undercooperativeagreementnumber#U30CS26935,TrainingandTechnicalAssistanceNationalCooperativeAgreement(NCA)for$325,000with0%ofthe

totalNCAprojectfinancedwithnon-federalsources.Thisinformationorcontentandconclusionsarethoseoftheauthorandshouldnotbeconstruedastheofficialpositionorpolicyof,norshouldanyendorsements

beinferredbyHRSA,HHSortheU.S.Government.”