# Presentation: 016092

## Homelessness and Mental Health Services: Data Collection and Analysis forPerformance & Outcome Measures 

**Michael Shank**
**Virginia DMHMRSAS**
**Learning Community Workgroup Meeting of the U.S. Departments of Health and Human Services, Housing and Urban Development, **
**Veterans Affairs, and Labor**** **
**Houston, Texas ****	****December, 2006**** **
**Expanded and revised version**

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

**in Richmond, Virginia**

**On any given night, 229 individuals are chronically homeless in Greater Richmond         **(2006 Point-in-Time Count)
**Approximately 60% of these individuals have a mental illness or co-occurring substance abuse disorder **(Leslie,2004)

## Chronic Homelessness and Hospital Care Data Analysis: What is the overlap?

**Richmond Homeless**
**Services**
**Clients**
**2003-2004**

**Homeless Management**
**Information System**
**(HMIS)**

**Virginia Health**
**Information System**
**(VHI)**

**Local Hospital**
**Psych **
**Inpatients**
**2003-2005**

## Initial Study of Richmond Area HMIS Data Homelessness and Psychiatric Inpatient Care

- HMIS data on 2,948 adults who sought homeless services during 2003 and 2004 were merged with VHI data on the utilization of psychiatric inpatient care in local hospitals from 2002 through 2004.
- Findings:
**541(18%) of these homeless adults were found to have a total of 2,190 psychiatric admissions during this period at an estimated cost in excess of $8 million (and over $3.5 million in 2004 alone). **
**On average, roughly $9,000 was spent for each of these homeless adults to spend 15 days per year in psychiatric units of local hospitals. **
**For a subset (29%) that had three or more admissions in a year’s time, that average cost rises to $21,000. **

## Chronic Homelessness and Hospital Care Local Data Analysis: What is the overlap?

**Richmond Homeless**
**Services**
**2003-2005**

**Homeless Management**
**Information System**
**(HMIS)**

**Virginia Commonwealth University Health System**
**(VCU/MCV Hospital)**

**One Public**
**General**
**Hospital**
**2002-2004**

## Richmond HMIS and VCU/MCV Local Public Hospital Data Analysis

**Homeward HelpNet (HMIS) Database**
- Identifies 5,660 adults enrolled in homeless services
- 2003 (n=801), 2004 (n=2,147), and 2005 (n=2,712).
- Records the date of enrollment as documentation of an episode of homelessness.
**VCU/MCV Local Public Hospital Database**
- Data on patients and episodes of hospital care.
- Matches with HelpNet individuals identified.
- Dates of care compared to HelpNet enrollment date for the 2004 cohort.

## Richmond HMIS and VCU/MCV Local Public Hospital Data Analysis

**Findings:**
**45% of Richmond-area homeless adults were patients of VCU/MCV hospital**
- in the calendar year in which they enrolled in the HelpNet (HMIS) database.
**For those enrolled during calendar year (CY) 2004, 56% were treated at VCU/MCV hospital**
- during the period 12 months before to 12 months after HelpNet enrollment date.

## Richmond HMIS and VCU/MCV Hospital Data Analysis: Frequent Use of MCV Hospital CareEach had episodes of hospital care an average of 4 times per year. Over a two-year period, the average was 6.5 times. 

## Policy Issue:  Do hospitals discharge into homelessness?

**Data Analysis**: **Emergency hospital episodes before and after HMIS enrollment**
- Hospital episodes peak around the month of homeless services enrollment, but occur both before and after episodes of homelessness.

**VCU-MCV Hospital Emergency Episodes of Care (n=3,889) **

**in the Emergency, Psychiatry, and General Medicine Departments **

**by Number of Months Before and After Richmond Area Adults (n=1,089) Enroll in Homeless Services**

- 27

- 18

- 22

- 23

- 17

- 15

- 39

- 28

- 26

- 38

- 47

- 87

- 164

- 80

- 84

- 64

- 70

- 65

- 56

- 41

- 50

- 59

- 55

- 52

- 89

- 78

- 85

- 78

- 77

- 92

- 87

- 97

- 85

- 101

- 100

- 257

- 221

- 144

- 156

- 110

- 89

- 98

- 88

- 111

- 108

- 100

- 118

- 93

- 0

- 50

- 100

- 150

- 200

- 250

- 300

- 350

- 400

- 450

- -12

- -11

- -10

- -9

- -8

- -7

- -6

- -5

- -4

- -3

- -2

- -1

- 0

- 1

- 2

- 3

- 4

- 5

- 6

- 7

- 8

- 9

- 10

- 11

**Number of Months Before and After Homeless Service Enrollment**

**Pre-Episodes Only**

**Post-Episodes Only**

**Pre- and Post-Episodes**

## Estimated hospital costs for these homeless patients Are highest for admissions to treat psychiatric disorders, followed by respiratory and circulatory disorders. These might be avoided by providing more comprehensive community care 

##  Policy Issue:  Can Homeless Housing Save Hospitals $ ?Data Analysis: A significant proportion of hospital charges go un-reimbursed Suggesting that the VCU/MCV hospital might benefit by investing in less expensive community-based options that lead to reduced admission rates among the homeless.

## Chronic Homelessness and Mental Health Care What is the overlap?

**CSB**
**(Community MH)**
** ****Services**
- through 6/30/05

**Local Hospital**
**Psych **
**Inpatients**
- 7/1/02 – 6/30/05

**Homeless**
**Services**
- 2003-2005

**Homeless Management**
**Information System**
**(HMIS)**

**Virginia Health**
**Information System**
**(VHI)**

**Community Services**
**Boards (CSBs) /**
**DMHMRSAS**
**Database**

## Richmond HMIS, CSBs, and VHI: MH Systems Data Analysis 

**4,355 adults enrolled in the HelpNet (HMIS)**
- homeless services database (greater Richmond area)
**20,274 adults in DMHMRSAS/CSB database**
- as CSB consumers in Planning District 15 (greater Richmond area)
**13,225 adults in Va Health Info (VHI) database **
- of local hospital psych inpatients in Planning District 15
**1,001 records matched HMIS to CCS**
- 4.9% of CCS and 23% of HelpNet
-    **722  records matched HMIS to VHI**
- 5.5% of VHI and 16% of HelpNet

**Notes:**
Records are matched based on a hashed social security number, which is estimated to be about 90% accurate.

## Richmond-Area Homeless Adults and Adult MH Consumers FY 03 - 05

**CSB**
** ****Services**

**Local Psych**
**Hospital**

**Homeless**
**Services**

**4,033**

**13,225**

**20,274**

**4,355**

**1,001**

**438**

**722**

**Notes:**
23% of HelpNet Clients in CSB services
16% of HelpNet Clients in local inpatient

4.9% of CSB clients experience homelessness (during 2-year period)

5.5% of local hospital inpatients experience homelessness (during 2-year period)

## Average Richmond-Area CSB Adult Consumer’s Local Psychiatric Hospital Use FY 03 – 05The average homeless CSB consumer, as compared to the average housed CSB consumer, had four times the number of admissions, three times the number of bed days, and three times the total estimated cost for local psychiatric inpatient care.

_**Housed (n=19,273)**_
**Hospital Use Per Client**
**Admissions = 0.57**
- FY03 = .16
- FY04 = .24
- FY05 = .17
**Bed Days = 4.46**
- FY03 = 1.23
- FY04 = 1.85
- FY05 = 1.38
**Est. Cost = $2,795**
- FY03 = $706
- FY04 = $1,165
- FY05 = $924

_**Homeless (n=1,001)**_
**Hospital Use Per Client**
**Admissions = 2.24**
- FY03 = .63
- FY04 = .87
- FY05 = .74
**Bed Days = 14.51**
- FY03 = 4.24
- FY04 = 5.77
- FY05 = 4.51
**Est. Cost = $8,846**
- FY03 = $2,289
- FY04 = $3,557
- FY05 = $2,999

**Notes:**
23% of HelpNet Clients in CSB services
16% of HelpNet Clients in local inpatient

4.9% of CSB clients experience homelessness (during 2-year period)

5.5% of local hospital inpatients experience homelessness (during 2-year period)

## CSB Homeless Consumer’s Low vs. High Local Psychiatric Hospital Use FY 03 – 05About 20% of homeless CSB consumers had three or more admissions in a year, accounting for most of the hospital use differences between the homeless and housed groups. Annual costs for this high inpatient user group accounted for 79% of the total. 

**Low Users (n=242)  24%**
**Cost $639,000/yr      21%**
**Admissions = 2.03**
- FY03 = .48
- FY04 = .90
- FY05 = .66
**Bed Days = 3.93**
- FY03 = 2.69
- FY04 = 6.11
- FY05 = 4.27
**Est. Cost = $7,921**
- FY03 = $1,487
- FY04 = $3,589
- FY05 = $2,845

**High Users (n=196)    20%**
**Cost $2,312,600/yr     79%**
**Admissions = 8.92**
- FY03 = 2.63
- FY04 = 3.35
- FY05 = 2.94
**Bed Days = 57.99**
- FY03 = 18.32
- FY04 = 21.91
- FY05 = 17.76
**Est. Cost = $35,397**
- FY03 = $9,854
- FY04 = $13,738
- FY05 = $11,805

**Notes:**
23% of HelpNet Clients in CSB services
16% of HelpNet Clients in local inpatient

4.9% of CSB clients experience homelessness (during 2-year period)

5.5% of local hospital inpatients experience homelessness (during 2-year period)

## Psychiatric Hospital Inpatient Cost for Shared Homeless Consumers

- CSB
-  Services

- Local Psych
- Hospital

- Homeless
- Services

**3%**

**2%**

**9%**

**Estimated **
**Psych Hospital Cost**
**$2.9 Million per Year**
**(~$2,600 - $35,000/person)**

**Notes:**
A subset (29% - 30%) have three or more admissions during the year.  Their average annual inpatient hospital costs are estimated at $21,000.

## Policy Implications:Psychiatric Hospital Inpatient Cost Offsets

- On average, roughly $6,700 is spent each year for a homeless adult with psychiatric disabilities in the Richmond area to spend a total of 11 days “housed” in local hospitals.
- For roughly 20% of this group, (i.e., those with 3 or more admissions per year), this one service costs $35,000.
- What does housing with supports cost?
- Who is willing to pay for it?

**Notes:**
The largest funding sources for these hospital costs are
Medicaid and Medicare
Self-Pay (probably means losses to the hospital)
State and Local Government
Managed Care Companies
Jails
Charities

## Data Analysis: Are homeless MH clients different?Richmond-Area CSB Adult ConsumersHoused vs. Homeless Comparison 

_**Housed**__ _(n=19,273)
- Average Age = 39.5
- Male= 53.3%
- African American = 41.2%
- Richmond Resident= 29.3%
- Bipolar/Mood Disorder Related 19.4%
- Schizophrenia Related 11.6%
- Alcohol Related 15.9%
- Any Cocaine Diagnosis 10.5%

_**Homeless**__ _(n=1,001)
- Average Age = 40.1
- Male= 50.9%
**African American = 68.6%**
**Richmond Resident= 61.7%**
- Bipolar/Mood Disorder Related 18.8%
- Schizophrenia Related 18.1%
- Alcohol Related 20.2%
**Any Cocaine Diagnosis 30.5% **

**Notes:**
Using such datasets could help us decide where to target what kind of services for what kinds of populations before they become homeless.

## Richmond-Area CSB Adult Consumers Housed vs. Homeless Comparison 

_**Housed**__ _(n=19,273)
**Residence at Admission**
**Private Residence 71.9%**
- Local Jail/Corrections   9.9%
- Homeless/Shelter   0.8%
**Employment at Admission**
- Employed Full Time   14.7%
- NILF-Disabled   14.6%
- Unemployed   11.9%
**Education at Admission **
- High School/Voc Ed.   26.5%
- Some HS/Voc Ed.   20.4%
- Some College   12.0%

_**Homeless**__ _(n=1,001)
**Residence at Admission**
- Private Residence 54.6%
- Local Jail/Corrections  13.1%
**Homeless/Shelter  12.5%**
**Employment at Admission **
- Employed Full Time    7.3%
- NILF-Disabled   22.2%
- Unemployed   21.3%
**Education at Admission **
- High School/Voc Ed.   27.1%
- Some HS/Voc Ed.   25.7%
- Some College   17.3%

## Richmond-Area CSB Adult Consumers Housed vs. Homeless Comparison 

_**Housed**__ __**% **_(n=19,273)
**Admitted to Hospital**
- FY 2003  7.9%
- FY 2004  13.4%
- FY 2005  9.5%
**High Annual Admissions (3+) **
- FY 2003  1.7%
- FY 2004  2.3%
- FY 2005  1.7%

_**Homeless **__**%**__ _(n=1,001)
**Admitted to Hospital**
**FY 2003  22.5%**
**FY 2004  33.6%**
**FY 2005   27.4%**
**High Annual Admissions (3+) **
**FY 2003  8.6%**
**FY 2004 10.7%**
**FY 2005 10.3%**

**Odds Ratio - Homelessness : High Psych Hospital Admits > 6:1**

**Notes:**
Two and one half to three times as many homeless CSB consumers experience local psych hospital admissions as compared to the “non-homeless” CSB consumers

They have 3.5 to 4 times the total number of admissions

And five to six times as many homeless CSB consumers experience three or more local psych hospital admissions per year as compared to the “non-homeless” CSB consumers

## Measuring MH Service Solutions Housing, Hospitals, & Other Outcomes

**Virginia**
**Programs **
**of**
**Assertive **
**Community **
**Treatment**

**PACT**

## PACT Outcomes in FY2004n = 1,151

- and another 9% had only one or two stays of ten or less days each on average = 83% “no or low” hospitalizations.
**84% of PACT consumers had stable housing**
- (two or fewer placements and no homelessness).
- 72% lived in private households.
- 94% had no arrests.
- 18% had some employment experience.

**PACT Outcomes in FY2004****n = 1,151**

## Other PACT Performance 

**and Outcome Monitoring**

- Information about PACT staff is also collected, such as:
- FTE level, educational degrees, professional license, position, and dates of tenure.
- PACT Staff “Fidelity to the Model” can therefore be measured and compared to Consumer Outcomes.

## Fidelity to PACT Staff the Model

- (100% of required staff 100% of the time = 100% 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,
- plus psychiatry and administrative support

## PACT Staff Fidelity Scores

## PACT Staff Fidelity Scores

- High >90%

- Low <90%

## n= 911 p=.0001

- 71

- 83

- 71

- 45

- 76

- 64

- 71

- 46

- 84

- 85

- 68

- 64

- 83

- N =

**PACT- State Hospital Readmission Rates by Team Fidelity Score**

- TFIDELITY

- 1.00000

- .98904

- .98630

- .95238

- .93585

- .90306

- .88558

- .81174

- .79808

- .74379

- .71852

- .69752

- .44194

- 95% CI POSTADM

- 2.0

- 1.5

- 1.0

- .5

- 0.0

- -.5

- High Team Fidelity

-      .00

-     1.00

**0.68**

**0.35**

- Low

- High

## n=1,151 p=.019

- 78

- 103

- 88

- 108

- 83

- 84

- 80

- 95

- 88

- 93

- 84

- 75

- 92

- N =

**PACT - % with Low or No Local Hospitalizations by Team Fidelity Score**

- TFIDELITY

- 1.00000

- .98904

- .98630

- .95238

- .93585

- .90306

- .88558

- .81174

- .79808

- .74379

- .71852

- .69752

- .44194

- 95% CI LONOHOSP

- 1.1

- 1.0

- .9

- .8

- .7

- .6

- High Team Fidelity

-      .00

-     1.00

**80%**

**86%**

- Low

- High

## n=1,136 p=.014

- 78

- 103

- 87

- 108

- 83

- 84

- 80

- 90

- 87

- 86

- 83

- 75

- 92

- N =

**PACT- Housing Placement Rate by Team Fidelity Score**

- Higher number of placements means lower housing stability

- Stable housing means two or fewer places lived during the year and no episodes homeless

- TFIDELITY

- 1.00000

- .98904

- .98630

- .95238

- .93585

- .90306

- .88558

- .81174

- .79808

- .74379

- .71852

- .69752

- .44194

- 95% CI  HOUSED

- 3.5

- 3.0

- 2.5

- 2.0

- 1.5

- 1.0

- .5

- High Team Fidelity

-      .00

-     1.00

**1.55**

**1.36**

- Low

- High

## p=.008

- 78

- 103

- 88

- 108

- 83

- 84

- 80

- 95

- 88

- 93

- 84

- 75

- 92

- N =

**PACT Combined Success Rates by Fidelity Score**

- Living in stable housing with few or no hospital admissions

- (Stable housing means 2 or fewer places lived and no episodes homeless)

- TFIDELITY

- 1.00000

- .98904

- .98630

- .95238

- .93585

- .90306

- .88558

- .81174

- .79808

- .74379

- .71852

- .69752

- .44194

- 95% CI SUCCES_1

- 1.0

- .9

- .8

- .7

- .6

- .5

- .4

- High Team Fidelity

-      .00

-     1.00

**72%**

**78%**

- Low

- High

## n=1,151 p=.019

- 78

- 103

- 88

- 108

- 83

- 84

- 80

- 95

- 88

- 93

- 84

- 75

- 92

- N =

**PACT - % with No Arrests by Team Fidelity Score**

- TFIDELITY

- 1.00000

- .98904

- .98630

- .95238

- .93585

- .90306

- .88558

- .81174

- .79808

- .74379

- .71852

- .69752

- .44194

- 95% CI NOARREST

- 1.1

- 1.0

- .9

- .8

- .7

- High Team Fidelity

-      .00

-     1.00

**92%**

**96%**

- Low

- High

## Example of Analyzing Outcomes by Other Factors

**PACT - Number of Consumers Arrested By Race and Team Fidelity Score**

- Note outliers – low number majority White/Caucasian, high number majority African American

**Example of Analyzing Outcomes by Other Factors**

## Policy Conclusion: PACT reduces hospital use and increases housing stability

**Policy Conclusion: PACT reduces hospital use and increases housing stability**

**Notes:**
Stable housing in this case is defined as living in only one or two places during the year and not experiencing homelessness or incarceration that results in a loss of housing (but the data is not very clear on that last point... PACT teams may be over-reporting by including jail stays even when the client’s apartment is maintained for them.)

Fairfax PACT’s numbers are similar in regards to stable housing, rising from 47% in 2001 to 78% in 2005 and “lived in 3 or more places” fell from 50% in 2001 to 13% in 2005.  The percentage of homeless clients, however, is much higher than the state average, with 33% in 2001 and 20% in 2005. This is in part by design – the Fairfax PACT does a good job of outreaching to homeless consumers.

## 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, decision making