[Slide 1]{.underline}

**Homelessness and Mental Health Services: Data Collection and Analysis
for\
Performance and Outcome Measures**

Michael Shank

Virginia DMHMRSAS

Learning Community Workgroup Meeting of the US Departments of Health and
Human Services, Housing and Urban Development, Veterans Affairs, and
Labor

Houston, Texas, December First, 2006

[Slide 2]{.underline}

**Chronic Homelessness and Mental Illness in Richmond, Virginia**

On any given night, 229 individuals are chronically homeless in Greater
Richmond; 2006 Point-in-Time Count

> Approximately 60 percent of these individuals have a mental illness or
> co-occurring substance abuse disorder; Leslie, 2004

[Slide 3]{.underline}

**Chronic Homelessness and Hospital Care Date Analysis: What Is the
Overlap**

The slide shows two concentric circles labeled Richmond Homeless
Services and Local Hospital Care.

[Slide 4]{.underline}

**Richmond HMIS and VCU Slash MCV Hospital Data Analysis**

Homeward Help-Net, HMIS Database

Identifies 5,660 adults enrolled in homeless services

> 2003, N equals 801; 2004, N equals 2,147; and 2005, N equals 2,712
>
> Records the date of enrollment as documentation of an episode of
> homelessness

VCU Slash MCV Hospital Database

Data on patients and episodes of hospital care

Matches with Help-Net individuals identified

Dates of care compared to Help-Net enrollment date for the 2004 cohort

[Slide 5]{.underline}

**Richmond HMIS and VCU Slash MCV Hospital Data Analysis**

Findings:

> 45 percent of Richmond-area homeless adults were patients of VCU slash
> MCV hospital
>
> In the calendar year, CY, in which they enrolled in the Help-Net,
> HMIS, database
>
> For those enrolled during CY 2004, 56 percent were treated at VCU
> slash MCV hospital
>
> During the period 12 months before to 12 months after Help-Net
> enrollment date

[Slide 6]{.underline}

**Policy Issue: Do hospitals discharge into homelessness**

**Data Analysis**: **Emergency hospital episodes before and after HMIS
enrollment**

Number of hospital episodes peak around the month of homeless services
enrollment

The following words appear above a bar graph:

> VCU-MCV Hospital Emergency Episodes of Care, N Equals 3,889, in the
> Emergency, Psychiatry, and General Medicine Departments by Number of
> Months Before and After Richmond Area Adults, N Equals 1,089, Enroll
> in Homeless Services

The X-axis is labeled Number of Months Before and After Homeless Service
Enrollment, and the Y-axis shows numbers. Bars marked Pre-episodes Only
run from 12 months before enrollment to one month before. In
chronological order, their values are 27, 18, 22, 23, 17, 15, 39, 28,
26, 38, 47, and 87. Bars marked Post-episodes Only run from the month of
enrollment to 11 months after. In chronological order, their values are
164, 80, 84, 64, 70, 65, 56, 41, 50, 59, 55, and 52. Bars marked Pre-
and Post-episodes run from 12 months before enrollment to 11 months
after. In chronological order, their values are 89, 78, 85, 78, 77, 92,
87, 97, 85, 101, 100, 257, 221, 144, 156, 110, 89, 98, 88, 111, 108,
100, 118, and 93.

[Slide 7]{.underline}

**Chronic Homelessness and Mental Health Care: What Is the Overlap**

The slide shows three concentric circles labeled CSB Community MH
Services, Local Psych Hospital Inpatient, and Homeless Services.

[Slide 8]{.underline}

**Richmond HMIS, CSB's, and VHI: MH Systems Data Analysis**

4,355 adults enrolled in the Help-Net HMIS

Homeless services database; greater Richmond area

20,274 adults in DMH CSB database

As CSB consumers in Planning District 15; greater Richmond area

13,225 adults in Virginia Health Info, VHI database

Of local psych hospital inpatients in Planning District 15

1,001 records matched HMIS to CCS

> 4.9 percent of CCS and 23 percent of Help-Net

722 records matched HMIS to VHI

> 5.5 percent of VHI and 16 percent of Help-Net

[Slide 9]{.underline}

**Richmond Area Homeless Adults and Adult MH Consumers, FY 2003 to
2005**

The slide shows three concentric circles labeled CSB Services, Local
Psych Hospital, and Homeless Services. The unshared portion of CSB
Services has the number 20,274. The unshared portion of Local Psych
Hospital has 13,225. The unshared portion of Homeless Services has
4,355. The portion shared between CSB Services and Local Psych Hospital
has 3,892. The portion shared between Local Psych Hospital and Homeless
Services has 722. The portion shared between Homeless Services and CSB
Services has 1,001. The portion shared among all three has 410.

[Slide 10]{.underline}

**Psychiatric Hospital Inpatient Cost for Shared Homeless Consumers**

The slide shows three concentric circles labeled CSB Services, Local
Psych Hospital, and Homeless Services. Each circle has an arrow pointing
into the central portion shared by all three. The arrow for CSB Services
is labeled 2 Percent. The arrow for Local Psych Hospital is labeled 3
Percent. The arrow for Homeless Services is labeled 9 Percent. An arrow
points out from the center to the following text:

> Estimated Psych Hospital Cost: 2.5 Million Dollars per Year, about
> 9,500 to 21,000 dollars per person

[Slide 11]{.underline}

**Policy Implications: Psychiatric Hospital Inpatient Cost Offsets**

On average, roughly 9,000 dollars is spent each year for homeless adults
with psychiatric disabilities to spend a total of 15 days housed in
local hospitals

For roughly a third of this group, who have three or more admissions per
year, this one service costs 21,000 dollars

What does housing with supports cost

Who is willing to pay for it

[Slide 12]{.underline}

**Data Analysis: Are Homeless MH Clients Different**\
**Richmond Area CSB Adult Consumers: Housed Versus Homeless Comparison**

Housed; N Equals 19,273

Average Age: 39.5

Male: 53.3 Percent

African American: 41.2 Percent

Richmond Resident: 29.3 Percent

Bipolar Slash Mood Disorder Related: 19.4 Percent

Schizophrenia Related: 11.6 Percent

Alcohol Related: 15.9 Percent

Any Cocaine Diagnosis: 10.5 Percent

Homeless; N Equals 1,001

Average Age: 40.1

Male: 50.9 Percent

African American: 68.6 Percent

Richmond Resident: 61.7 Percent

Bipolar Slash Mood Disorder Related: 18.8 Percent

Schizophrenia Related: 18.1 Percent

Alcohol Related: 20.2 Percent

Any Cocaine Diagnosis: 30.5 Percent

[Slide 13]{.underline}

**Richmond Area CSB Adult Consumers: Housed Versus Homeless Comparison**

Housed; N Equals 19,273

Residence at Admission

> Private Residence: 71.9 Percent
>
> Local Jail Slash Corrections: 9.9 Percent
>
> Homeless Slash Shelter: 0.8 Percent

Employment at Admission

> Employed Full Time: 14.7 Percent
>
> NILF Disabled: 14.6 Percent
>
> Unemployed: 11.9 Percent

Education at Admission

> High School Slash Vocational Education: 26.5 Percent
>
> Some High School Slash Vocational Education: 20.4 Percent
>
> Some College: 12.0 Percent

Homeless; N Equals 1,001

Residence at Admission

> Private Residence: 54.6 Percent
>
> Local Jail Slash Corrections: 13.1 Percent
>
> Homeless Slash Shelter: 12.5 Percent

Employment at Admission

> Employed Full Time: 7.3 Percent
>
> NILF Disabled: 22.2 Percent
>
> Unemployed: 21.3 Percent

Education at Admission

> High School Slash Vocational Education: 27.1 Percent
>
> Some School Slash Vocational Education: 25.7 Percent
>
> Some College: 17.3 Percent

[Slide 14]{.underline}

**Richmond Area CSB Adult Consumers: Housed Versus Homeless Comparison**

Housed; N Equals 19,273

Percent Admitted to Hospital

> FY 2003: 7.9 Percent
>
> FY 2004: 13.4 Percent
>
> FY 2005: 9.5 Percent

Admissions per Consumer

> FY 2003: 0.16 Percent
>
> FY 2004: 0.24 Percent
>
> FY 2005: 0.17 Percent

High Annual Admissions; 3 Plus

> FY 2003: 1.7 Percent
>
> FY 2004: 2.3 Percent
>
> FY 2005: 1.7 Percent

Homeless; N Equals 1,001

Percent Admitted to Hospital

> FY 2003: 22.5 Percent
>
> FY 2004: 33.6 Percent
>
> FY 2005: 27.4 Percent

Admissions per Consumer

> FY 2003: 0.63 Percent
>
> FY 2004: 0.87 Percent
>
> FY 2005: 0.74 Percent

High Annual Admissions; 3 Plus

> FY 2003: 8.6 Percent
>
> FY 2004: 10.7 Percent
>
> FY 2005: 10.3 Percent

Odds Ratio: Homelessness: High Psych Hospital Admits More than 6 to 1

[Slide 15]{.underline}

**Measuring MH Service Solutions: Housing and Hospital Outcomes**

Virginia Programs of Assertive Community Treatment; Pact

[Slide 16]{.underline}

**Pact Outcomes in FY 2004; N Equals 1,151**

74 percent had no hospital admissions

> Another 9 percent had only one or two stays of 10 days or less each on
> average, equal to 83 percent no or low hospitalizations

84 percent had stable housing

> Two or fewer placements and no homelessness

72 percent lived in private households

94 percent had no arrests

18 percent had some employment experience

[Slide 17]{.underline}

**Other Pact Performance and Outcome Monitoring**

Information about Pact staff members is also collected, such as:

> FTE level, educational degrees, professional license, position, and
> dates of tenure

Pact staff fidelity to the model therefore can be measured and compared
to consumer outcomes

[Slide 18]{.underline}

**Fidelity to Pact Staff the Model: 100 percent of required staff 100
percent of the time equals 100 percent score**

Virginia Pact Teams should include:

> A team leader
>
> Three nurses
>
> Five or more clinicians, half of whom hold a master's degree,
> including a vocational specialist and a substance abuse specialist
>
> A peer counselor
>
> Psychiatry and administrative support

[Slide 19]{.underline}

**Pact Staff Fidelity Scores**

A point graph is labeled Staff Fidelity Scores: 2000, 2002, 2004. The
X-axis lists Pact teams by letter, and the Y-axis shows percentages.
Team L registers 97.4 percent for July to December 2000, 94.6 percent
for CY 2002, and 69.7 percent for FY 2004. Team J registers 45.6 percent
for July to December 2000, 69.9 percent for CY 2002, and 71.8 percent
for FY 2004. Team F registers 95.2 percent for July to December 2000,
80.9 percent for CY 2002, and 74.4 percent for FY 2004. Team B registers
59.1 percent for July to December 2000, 78.6 percent for CY 2002, and
79.8 percent for FY 2004. Team G registers 67.5 percent for July to
December 2000, 81.8 percent for CY 2002, and 81.2 percent for FY 2004.
Team D registers 78.1 percent for July to December 2000, 100 percent for
CY 2002, and 88.5 percent for FY 2004. Team A registers 93.7 percent for
July to December 2000, 95.3 percent for CY 2002, and 90.3 percent for FY
2004. Team C registers 80.6 percent for July to December 2000, 97.9
percent for CY 2002, and 93.6 percent for FY 2004. Team I registers 48.3
percent for July to December 2000, 74.6 percent for CY 2002, and 95.2
percent for FY 2004. Team E registers 100 percent for July to December
2000, 97.8 percent for CY 2002, and 98.6 percent for FY 2004. Team M
registers 83.3 percent for July to December 2000, 82.2 percent for CY
2002, and 98.9 percent for FY 2004. Team O registers 93.8 percent for
July to December 2000, 100 percent for CY 2002, and 100 percent for FY
2004. Team H registers 81.2 percent for July to December 2000, 85.7
percent for CY 2002, and nothing for FY 2004. Team N registers 68.5
percent for July to December 2000, 81.3 percent for CY 2002, and nothing
for FY 2004.

[Slide 20]{.underline}

**Pact Staff Fidelity Scores**

A point graph is labeled Staff Fidelity Scores: 2000, 2002, 2004. The
X-axis lists Pact teams by letter, and the Y-axis shows percentages. At
the upper left of the graph is written High More than 90 Percent, Low
Less than 90 Percent. Team L registers 97.4 percent for July to December
2000, 94.6 percent for CY 2002, and 69.7 percent for FY 2004. Team J
registers 45.6 percent for July to December 2000, 69.9 percent for CY
2002, and 71.8 percent for FY 2004. Team F registers 95.2 percent for
July to December 2000, 80.9 percent for CY 2002, and 74.4 percent for FY
2004. Team B registers 59.1 percent for July to December 2000, 78.6
percent for CY 2002, and 79.8 percent for FY 2004. Team G registers 67.5
percent for July to December 2000, 81.8 percent for CY 2002, and 81.2
percent for FY 2004. Team D registers 78.1 percent for July to December
2000, 100 percent for CY 2002, and 88.5 percent for FY 2004. Team A
registers 93.7 percent for July to December 2000, 95.3 percent for CY
2002, and 90.3 percent for FY 2004. Team C registers 80.6 percent for
July to December 2000, 97.9 percent for CY 2002, and 93.6 percent for FY
2004. Team I registers 48.3 percent for July to December 2000, 74.6
percent for CY 2002, and 95.2 percent for FY 2004. Team E registers 100
percent for July to December 2000, 97.8 percent for CY 2002, and 98.6
percent for FY 2004. Team M registers 83.3 percent for July to December
2000, 82.2 percent for CY 2002, and 98.9 percent for FY 2004. Team O
registers 93.8 percent for July to December 2000, 100 percent for CY
2002, and 100 percent for FY 2004. Team H registers 81.2 percent for
July to December 2000, 85.7 percent for CY 2002, and nothing for FY
2004. Team N registers 68.5 percent for July to December 2000, 81.3
percent for CY 2002, and nothing for FY 2004.

[Slide 21]{.underline}

**Pact Housing Placements by Team Fidelity**

Higher number of placements means housing instability

Stable housing means two or fewer places lived and no homeless episodes

On a line graph, the Y-axis is labeled 95 Percent CI Housed. The X-axis,
labeled T-Fidelity, lists the following values of N from left to right:
92, 75, 83, 86, 87, 90, 80, 84, 83, 108, 87, 103, and 78. Written
diagonally near these numbers are the following values: 0.44194,
0.69752, 0.71852, 0.74379, 0.79808, 0.81174, 0.88558, 0.90306, 0.93585,
0.95238, 0.98630, 0.98904, and 1.00000. The words High Team Fidelity are
to the right of the graph, followed by a legend to indicate one line
marked 0.00 and another marked 1.00. In the upper left of the graph is
written Low Less than 90 Percent. In the upper right of the graph is
written High More than 90 Percent. Each point on the lines has a
vertical bracket to show a range. The 0.00 line covers the first seven
points, starting from a high around 2.6 and bumpily ending around 1.5,
with a low of about 1.0. The 1.00 line covers the last six points,
starting and ending around 1.4, with a low of about 1.2 and a high of
about 1.7.

[Slide 22]{.underline}

**Pact: Low or No Hospitalization Rates by Team Fidelity Score**

On a line graph, the Y-axis is labeled 95 Percent CI Low or No
Hospitalization. The X-axis, labeled T-Fidelity, lists the following
values of N from left to right: 92, 75, 83, 86, 87, 90, 80, 84, 83, 108,
87, 103, and 78. Written diagonally near these numbers are the following
values: 0.44194, 0.69752, 0.71852, 0.74379, 0.79808, 0.81174, 0.88558,
0.90306, 0.93585, 0.95238, 0.98630, 0.98904, and 1.00000. The words High
Team Fidelity are to the right of the graph, followed by a legend to
indicate one line marked 0.00 and another marked 1.00. In the upper left
of the graph is written Low Less than 90 Percent. In the upper right of
the graph is written High More than 90 Percent. Each point on the lines
has a vertical bracket to show a range. The 0.00 line covers the first
seven points, starting from a low around 7.3 and ending around 7.6, with
a high of about 8.8. The 1.00 line covers the last six points, starting
from a low around 7.7 and ending around 8.8, with a high of about 9.2.

[Slide 23]{.underline}

**Pact Consumers' Housing and Hospitalizations by Fiscal Year**

On a bar and line graph, the X-axis lists fiscal year periods, the left
Y-axis for bars is labeled Percent by Housing Type, and the right Y-axis
for lines is labeled Number of Consumers and Hospital Admissions. Each
fiscal year starts on July First and ends on June Thirtieth. Below the
graph is a table listing the same information but with the bar and line
colors identified. The Stable Housing percentage was 61 in FY 2000 to
2001, 64 in FY 2001 to 2002, 71 in FY 2002 to 2003, 74 in FY 2003 to
2004, and 80 in FY 2004 to 2005. The Lived in Three or More Places
percentage was 38 in FY 2000 to 2001, 34 in FY 2001 to 2002, 27 in FY
2002 to 2003, 24 in FY 2003 to 2004, and 17 in FY 2004 to 2005. The
Homeless percentage was 13 in FY 2000 to 2001, 13 in FY 2001 to 2002, 10
in FY 2002 to 2003, 10 in FY 2003 to 2004, and 7 in FY 2004 to 2005. The
number of Consumers was 1,056 in FY 2000 to 2001, 1,178 in FY 2001 to
2002, 1,313 in FY 2002 to 2003, 1,168 in FY 2003 to 2004, and 1,215 in
FY 2004 to 2005. The number of Local Hospital Admissions was 589 in FY
2000 to 2001, 690 in FY 2001 to 2002, 599 in FY 2002 to 2003, 610 in FY
2003 to 2004, and 509 in FY 2004 to 2005.

[Slide 24]{.underline}

**Performance and Outcome Measurements in Human Services**

What gets measured gets done

If you measure it, you can manage it

Measure what matters

Keep staff invested in the reported outcomes

Keep it simple

To understand and track

Feed it back

Use reports to focus discussions and decisionmaking