# Presentation: 753059

## Carol Wilkins
Director of Intergovernmental Policy
December 2003
www.csh.org

- Director of Intergovernmental Policy
- December 2003
- www.csh.org

- The Dynamics of Homelessness and the Impact of Supportive Housing on Services Use and Costs

## Our Mission

- CSH helps communities create affordable housing with services to prevent and end homelessness.

## Acknowledgements

- Much of the data and many of the slides included in this presentation were prepared by
** ****Dennis Culhane, Ph.D.**
**Center For Mental Health Policy & Services Research**
**University of Pennsylvania**
- The Corporation for Supportive Housing works in partnership with
- Dr. Culhane and other researchers to increase our knowledge about the dynamics of homelessness and the impact of supportive housing.
** **
** **

## Point and Period Prevalence of Public Shelter Utilization: New York and Philadelphia

## Annual Rates of Shelter Utilization for Selected Populations

## Cluster Distributions: Persons and Shelter Days Consumed (Single Adults in New York)

**Transitional:**
**1.36 stays**
**57.8 days**
**Episodic:**
**4.85 stays**
**263 days**
**Chronic:**
**2.27 stays**
**637.8 days**

## Disability Condition & Veteran Status By Cluster (Single Adults in Philadelphia)

## Implications for Designing Solutions to Homelessness

- Chronically homeless people need permanent supportive housing
- Transitionally homeless need:
- Prevention
- Help for a quick return to housing
- Episodically homeless people need:
- “Low Demand” or harm reduction models including safe havens
- Residential treatment/transitional housing

## The Impact of Supportive Housing on Services Use for Homeless Persons with Mental Illness in New York City 

- The Impact of Supportive Housing on Services Use for Homeless Persons with Mental Illness in New York City
** **
-  Dennis Culhane, Ph.D.
-   Stephen Metraux, M.A.
- Trevor Hadley, Ph.D.

- Center For Mental Health Policy & Services Research
- University of Pennsylvania

## Funding Sources:

** **** **
- Fannie Mae Foundation
- The United Hospital Fund of New York
- The Conrad N. Hilton Foundation
- The Rhodebeck Charitable Trust
- The Corporation for Supportive Housing
** **
** **

## NY/NY: Background

- Agreement between NY State and NY City
- Funds capital, operating, and service costs for 3,600 supportive housing units in NYC
- Placement recipients must have an SMI diagnosis & a record of homelessness
- Data available on 4,679 NY/NY placement records between 1989-97

## Research Question

** **

- City shelters
- State psychiatric hospitals
- State Medicaid services
- City hospitals (HHC)
- Veterans Administration hospitals
- State prisons
- City jails

- How do NY/NY housing placements affect the use of:

## Data Sources

**  **
- NY/NY Housing Placements: 1989-97
- Single Shelter Users and Stays: 1987-99
- State Hospital Users & Stays: 1990-96
- Municipal Hospital Users & Stays (non-Medicaid): 1989-96
- Medicaid-Reimbursed Inpatient Hospital Stays: 1993-97
- Medicaid-Reimbursed Outpatient Visits: 1993-97
- Veterans Hospital Stays: 1992-99
- State Criminal Justice Prison Use & Convictions: 1987-97
- City Jail Use: 1987-99

## Research Method #1

**2 Years**

**2 Years**

**Post-NY/NY**

**Placement**

**Pre-NY/NY**

**Placement**

**Pre-Post Analysis**

## Research Methods #2

**Control**

**Pool**

**(observations**

**from services**

**system)**

**Cases**

**4,679**

**Persons w/**

**NY/NY**

**Placement**

**P**

**re-Match**

** **

**Matched On:**

**  **

**Race; Sex; Age**

**SA & MH Use**

**Matched**

**Pairs**

**Best Match on:**

**Pre Intervention**

**Services Use**

## The Cost of Homelessness

## The Cost of Homelessness #2

## Reductions in Shelter Use (NYC Dept. Of Homeless Services)

## Reductions in Inpatient Hospital Use (NYS Office of Mental Health)

## Reductions in Public Hospital Use (NYC Health & Hospitals Corporation – non-MA)

## Reductions in Medicaid-Reimbursed Inpatient Hospital Use (NYS Department of Health)

## Increases in the Use of Medicaid-Reimbursed Outpatient Services  (NYS Department of Health)

## Reductions in VA Inpatient Hospital Use (US Department of Veterans Affairs)

## Reductions in Incarceration in State Prison (NYS Dept. Of Criminal Justice Services)

## Reductions in Incarceration in City Jails (NYC Department Of Corrections)

## NY/NY Savings: Per Housing Unit Per Year

## Cost Savings #2

## NY/NY Housing Costs

##  NY/NY Housing - Costs and Savings

## Summary of Findings

- Homeless mentally ill are heavy service users (37% of last 2 years spent in institutional settings)
- Providing services for homeless mentally ill is expensive ($40,449 per person per year)
- Providing NY/NY housing for homeless mentally ill reduced costs by 30% ($16,272 in savings per unit)

## NY/NY Cost Study Conclusions 

- 95% of supportive housing costs offset by savings from service reductions *attributable* to housing placements
- Study underestimated savings associated with program-funded services and crime
- Study did not quantify benefits to consumers or neighbors
- NY/NY was a sound public investment

## Looking Beyond New York City

- CSH has supported efforts to measure the impact of supportive housing on services use and costs in other States, including:
- Connecticut
- Minnesota
- California
- New results available from a study of VA supported housing program (Rosenheck)
- State and local governments can partner with supportive housing providers and tenants to measure the impact of a range of models

## State and Local Government Strategies

- Measure impact of supportive housing on use of services in a few service systems where
- Data is available and consistent from year to year
- Reductions will have greatest fiscal or policy impact
- Program design and logic model predict outcomes
- Measure service use 12 – 24 months before and after homeless people move into supportive housing
- Use supportive housing wait lists as control group if selection minimizes differences

## Consistent Findings: Housing + Services Make a Difference

- More than 80% of supportive housing tenants are able to maintain housing for at least 12 months
- Most supportive housing tenants engage in services, even when participation is not a condition of tenancy
- Use of the most costly (and restrictive) services in homeless, health care, and criminal justice systems declines
- Nearly any combination of housing + services is more effective than services alone

## San Francisco Health Housing and Integrated Services Network

- Two permanent supportive housing projects: 236 study participants entered housing (1994 – 1998)
- Shelter + Care program targeted homeless adults with co-occurring mental illness, substance abuse and/or HIV/AIDS
- Wait list with lottery to select for housing + few applicants denied housing (no clean & sober requirements) = random assignment to housing
- Hospital and treatment system data provided by SF Department of Public Health
- Analysis by Tia Martinez, UC Berkeley

## Decline in Total Number of Emergency Department Visits (n=236)

## Decline in Total Number of Hospitalizations (n=236)

## Changes in Emergency Department Use From Year 1 to Year 2 Among Cases and Controls 

**Changes in Emergency Department Use From Year 1 to Year 2 Among Cases and Controls **

## Supportive Housing Reduces Use of and Costs for:

- Hospital inpatient care for medical and psychiatric conditions
- Hospital emergency room visits – especially for the most frequent users of ER
- Psychiatric emergency and institutional care
- Residential mental health & substance abuse treatment – especially detox
- Jails and prisons
- Emergency shelters

## Supportive Housing May Increase Use of and Costs for:

- Outpatient primary and specialty medical care
- Some mental health services (e.g. case management, pharmacy)
- Methadone (more consistent participation)
- Services to address substance abuse problems, including services delivered outside of traditional treatment programs
- Vocational and employment services
- Probation

## Policy Implications

- Costs and savings are often in different systems of care – and sometimes at different levels of government
- Coordinated investments are needed for housing and services
- Opportunities to maximize savings may be greatest when focusing on chronic homelessness and/or homeless frequent users of emergency and inpatient services

## The Bottom Line

- “Standard care” emergency responses to chronic homelessness are very costly
- Investments in supportive housing will significantly reduce services use and public costs in some systems of care
- The net cost of achieving much better outcomes is relatively small – if savings can be re-invested

## Carol Wilkins
Director of Intergovernmental Policy
October 2003
www.csh.org

- Director of Intergovernmental Policy
- October 2003
- www.csh.org

- The Dynamics of Homelessness and the Impact of Supportive Housing on Services Use and Costs