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Integrated Care for the Chronically Homeless

State: TX Type: Model Practice Year: 2019

Houston, Texas is the fourth largest city in the U.S., with an estimated population of 2.2 million individuals. It is a minority-majority city, with people of color making up over 68% of the population. The Houston Health Department (HHD) (www.houstonhealth.org) serves as the lead health authority for the City of Houston. HHD is the first large public health department in the state of Texas to become accredited by the Public Health Accreditation Board (PHAB). As a PHAB accredited public health department, HHD is progressive, surpasses performance expectations, and exhibits the organizational and technical capacity to respond to community needs. HHD provides traditional core public health services to all Houston residents but also serves the role as convener and backbone agency for many community interventions. Through the development of partnerships and collaborations, HHD has been able to sustain many interventions initiated through outside funders, as well as leverage resources to implement interventions when funding is limited. According to 2018 estimates from Harris County, there were 11,665 chronically homeless individuals within placed in permanent supportive housing (PSH) since 2012 with 2,650 individuals placed in the previous calendar year. PSH is a long-term housing solution for individuals with disabling conditions (i.e., serious mental illness, diagnosable substance abuse disorder, developmental disability, disability due to injury or chronic illness) who have been chronically homeless. In PSH, supportive services are offered to tenants to address their complex medical and behavioral health needs associated with frequently co-occurring disabling condition(s). Despite the elevated service delivery needs of the population being served in PSH, without best practices as a guide, PSH service delivery models tend to be varied with the outcomes from such programs differing in success. The development and evaluation of a replicable service delivery model for clients served in PSH has potential to increase access to care and the health for this vulnerable population with complicated care needs, as highlighted by a recent report by the National Academies of Sciences, Engineering and Medicine. To address this gap in understanding, the COH Health Department worked with two Federally Qualified Health Centers (FQHC) to design and offer collaborative care to individuals once assigned to PSH. Both programs included: 1.) Clinical case managers (CCM) to conduct regular assessments of the client's well-being and implement behavioral health interventions (e.g., substance use treatment or recovery); 2.) Community health workers (CHW) to address identified health needs and navigate care (e.g., appointments, benefits); and 3.) An onsite registered nurse (RN) who worked to assess immediate healthcare and care coordination needs. One service delivery model (Healthcare for the Homeless Houston - HHH) was designed and implemented in partnership with a homeless social service organization charged with clinical case management (SEARCH Homeless Services). Consistent with the highest level of care integration, all team members at the FQHC and the coordinated care team worked collaboratively using a single coordinated plan of care with a shared electronic health record. The RN translated needs to medical professionals at the FQHC and worked with other members of the coordinated care team including the CHW and CCM to implement clinical recommendations (e.g., medication adherence). The primary goal/objective of the model was to increase the health-related quality of life of participants, including: 1.) Increasing the client's self-reported physical health-related quality of life as measured by the PCS subscale of the SF-36. 2.) Increasing the client's self-reported mental health-related quality of life as measured by the MCS subscale of the SF-36. 3.) Reducing self-reported indicators of depression as measured by the PHQ-9. 4.) Reducing client utilization of emergency rooms over two years. To establish the unique contribution of the service delivery model, separate from the benefits of housing alone, two PSH collaborative care models were compared. Consistent with a natural experiment, group assignment was not randomized but both models shared inclusion criteria and assignment was done arbitrarily. All objectives were met with significant differences in all HRQoL items including the SF-36 PCS, SF-36 MCS and PHQ over time. After two years, the total number of ER visits for those receiving services through the HHH/SEARCH model decreased by over 70%. The service delivery model suggests potential for increasing the HRQoL and decreasing emergency room use of those enrolled in the program. Given the great promise demonstrated by this practice in increasing the health and wellbeing of those served, there have been discussions about continuing to support funding through partnerships with Medicaid managed care organizations which may be able to cover the cost of services for Medicaid members if there is a demonstration of cost-saving.
Statement of the problem/public health issue: Each night in the United States (US), there are nearly 87,000 individuals who meet the US Department of Housing and Urban Development's (HUD) criteria for chronic homelessness. This includes individuals with a disabling condition who have been homeless (without a nighttime residence) for at least 12 months for one year or four times within the past three years. The current number of chronically homeless individuals reflects a 25% decrease in chronic homelessness over the past decade. This reduction is likely a reflection of the increase in Permanent Supportive Housing (PSH), a long-term housing solution for individuals with disabling conditions (i.e., serious mental illness, diagnosable substance abuse disorder, developmental disability, disability due to injury or chronic illness) who have been chronically homeless. In addition to providing long-term housing, depending on available resources of the service provider, services are made available to PSH tenants to address the complex medical and behavioral health needs associated with frequently co-occurring disabling condition(s). The continued housing of the new tenants is not, however, contingent upon their willingness or commitment to accessing these services. Thus, this model is designed to provide a comprehensive system of care without consequences for those who are unwilling, unready or unable to take advantage of services. Since service access is voluntary for PSH tenants, the likelihood that they will seek care may depend on the number of barriers that they encounter and the ease with which these barriers are overcome. Asking someone in PSH to prioritize and address their needs individually, as is done in the traditional fragmented healthcare system, may be unrealistic for someone with competing mental, behavioral and physical health needs. Yet, despite the elevated service care delivery needs of the population being served in PSH, there is limited data on best practices for care delivery in PSH. Without best practices as a guide, service delivery models within PSH tend to be varied with the outcomes from such programs differing in success. The development and evaluation of a replicable service delivery model for clients served in PSH has potential to increase access to care and the health and wellbeing of this vulnerable population with complicate care needs. The National Academies of Sciences, Engineering and Medicine (NASEM) recently released a report highlighting the need for more data on the health benefits and best practices for service delivery within PSH. Description of the Target Population: The US Department of Housing and Urban Development (HUD) mandates an annual count of all individuals experiencing homelessness on a given night called (i.e., the Point-In-Time Count- PIT). According to the 2018 PIT estimates from Harris County, there have been 11,665 individual placements in PSH since 2012 with 2,650 individuals placed in the previous calendar year. This does not include the placement of veterans through the HUD-VASH. New Hope Housing, the housing provider and collaborative partner for the current service delivery model, has over 1,000 single residency occupancy units. From 2014-2017, the Houston Health Department (HHD) provided collaborative care to 323 individuals in PSH with 210 individuals receiving care through the HHH/SEARCH service delivery model. At baseline, the mean age of the clients in the HHH/SEARCH group were (N=210, M=50.68, SD=10.62). The majority of participants in both groups were male (69.04%, N=223), Black (64.91%, N=209) and had a serious mental illness (71.52%, N=231). Innovations and Benefits of Current Practice: Current service delivery models offered to individuals residing in permanent supportive housing (PSH) vary based on the resources and expertise of the service providers. Many of the residents in PSH have co-occurring conditions, suggesting the importance of collaborative or integrative care models. Yet, best practices on collaborative care models for those offering services in PSH are limited. To address this gap in understanding, the HHD provided contracts to two Federally Qualified Health Centers (FQHC) to design and offer collaborative care to individuals once assigned to PSH. Both programs included: 1.) Clinical case managers (CCM) to conduct regular assessments of the client's well-being and implement behavioral health interventions (e.g., substance use treatment or recovery); 2.) Community health workers (CHW) to address identified health needs and navigate care (e.g., appointments, benefits); and 3.) An onsite registered nurse (RN) who worked to assess immediate healthcare and care coordination needs. One of the service delivery models offered through Healthcare for the Homeless-Houston (HHH) was designed and implemented in partnership with a homeless social service organization (SEARCH homeless services) charged with clinical case management. In this service model, all clients were navigated to the partnering FQHC for physical or behavioral health needs as appropriate. Consistent with the highest level of care integration, all team members at the FQHC and the coordinated care team worked collaboratively towards a single coordinated plan of care with a shared electronic health record. The RN translated needs to medical professionals at the FQHC and worked with other members of the coordinated care team including the CHW and CCM to implement clinical recommendations (e.g., medication adherence). Evidence Base: The current practice was developed in consideration of a number of evidence-based frameworks and practices. First, both Housing First and Permanent Supportive Housing models are evidence-based (see SAMHSA as an example: https://store.samhsa.gov/product/Permanent-Supportive-Housing-Evidence-Based-Practices-EBP-KIT/SMA10-4510). The HHH/SEARCH model adhered to evidence-based recommendations regarding both Housing First and PSH programs. The service delivery model within PSH, was consistent with Henwood, Siantz, Hrouda, Innes-Goumbery and Golmer's (2017) description of embedded partnership models in which a full-time nurse is embedded within a coordinated care team. Finally, all staff in the HHH/SEARCH model received training-with the majority receiving coaching- in both Stages of Change and Motivational Interviewing, also an evidence-based practice per SAMHSA. Thus, the service delivery model was developed based on existing literature on best practices. A manuscript detailing the current service delivery model was recently accepted in the American Journal of Public Health, continuing to add to the evidence base in this field.1 1 Please note that portions of this application are directly from the manuscript currently in press at the American Journal of Public Health.
Goal(s) and objectives of practice: The practice was designed to provide integrative care through an innovative service delivery model to those placed in permanent supportive housing. The primary goal/objective of the practice was to increase the health-related quality of life of the clients. Specifically, the four goals/objectives were as follows: Objective #1: Significantly and meaningfully increase the client's self-reported physical health-related quality of life as measured by the PCS subscale of the SF-36 Objective #2: Significantly and meaningfully increase the client's self-reported mental health-related quality of life as measured by the MCS subscale of the SF-36 Objective #3: Significantly reduce the client's self-reported symptoms of depression over time as measured by the PHQ-9 Objective #4: Reduce client utilization of emergency rooms over two years Eligibility Criteria: Individuals who met the criteria for chronic homelessness as defined by HUD were eligible to participate in the program. This included individuals with a qualifying disability, and three self-reported emergency room visits in the two years prior to enrollment. Individuals were screened for eligibility and assigned to one of the two FQHC with contracts through the HHD by the regional homeless Continuum of Care's (CoCs) Coordinated Access/Entry program as required by HUD. Timeframe: Funding for this program was awarded in 2013 with the first client enrolled in 2014. Individuals continue to be housed and receive services through present. The evaluation of the practice is based on years 2014-2017 (the latest data collection point at the time of the evaluation). Stakeholder Engagement: There were a number of stakeholders involved in the development and implementation of this practice. The Houston Health Department and two Federally Qualified Health Centers were the primary subaward recipients. Each FQHC developed a different collaborative care model, one with a homeless service organization to provide clinical case management. All partners worked closely with the housing provider. Therefore, in total, there was a minimum of four key stakeholders outside of the HHD. Prior to implementation, the need for an integrated system of care for the homeless had been a subject of ongoing discussion between HHD and the Mayor's Office for Homeless population. Several models of interventions to improve the health status of the homeless population, implemented by other large U.S. cities were jointly discussed. The feasibility of implementation of various models were discussed. In the past, the lack of sufficient funding and limited resources had delayed the implementation of some of the ideas that were discussed. Although HHD was successful in writing and receiving funding for this initiative, other stakeholders such as the Mayor's Office, providers and agencies that served the homeless population, academic partners that had conducted research on homeless in the past, the Housing and Urban Development (HUD) and grassroots service providers were involved at different stages during the development of the application, from conception to implementation. A Request for Proposals (RFP) was developed by HHD, and two community partners (Federally Qualified Health Centers) were selected to provide services. Each FQHC developed a different collaborative care model, one with a homeless service organization to provide clinical case management. All partners worked closely with the housing provider. While HHD has been successful in securing funding for this project, the department relies on our community partners for their expertise in implementing and providing the services related to this project. The subaward recipients worked closely with additional community partners once funding was awarded, including the Mayor's Special Assistant on Homeless Issues and New Hope Housing (the PSH housing provider). Costs and Funding: This project required a significant investment upfront by the City of Houston. This practice was funded by Medicaid supplemental funding through the Delivery System Reform Incentive Payment (DSRIP) pool of the 1115 Medicaid Demonstration Waiver. To receive the supplemental funding, a governmental entity (the City of Houston in this case) must provide funding to the Texas Health and Human Services Commission (HHSC), which will then have the funds matched” by the federal government and sent back to the Medicaid provider (Houston Health Department) designated by the funding governmental agency (this process is called an intergovernmental transfer” or IGT”). The following budget provides costs for the first year of project implementation. The primary costs for HHD were for contracted services to deliver the project. The budget for the HHD were as follows: Description Actual budget Personnel Services $89,696.00 Subrecipient Contract Services $1,137,833.00 Management Consulting Services $9,500.00 Miscellaneous Support Services $25,890.00 Travel $9,090.00 Because the 1115 Waiver DSRIP program was designed as a pay for performance, HHD was able to provide money to the service providers for the planning stage and expenses for the first 6 months of programming. This money was gradually returned” to HHD by the service providers by the end of the contract period. This service delivery package is estimated to cost $8,000 per person per year.
Evaluation Process: The current study assessed the impact of collaborative care on the health-related quality of life (HRQoL) of individuals in PSH. To establish the unique contribution of the service delivery model, separate from the benefits of housing alone, two PSH collaborative care models were compared. Participants in the comparison group were not directed to a single FQHC, preventing the possibility of a single coordinated plan of care. Thus, the evaluation investigated whether an integrated service delivery model with a single coordinated plan of care (the HHH/SEARCH service delivery model) would significantly and meaningfully increase the HRQoL of enrolled participants relative to participants enrolled in a similar service delivery model without a single, coordinated plan of care (the comparison). Consistent with a natural experiment, group assignment was not randomized but both models shared inclusion criteria and assignment was done arbitrarily by the regional homeless Continuum of Care's (CoCs) Coordinated Access/Entry program as required by HUD. Data collected from 2014 through 2017 was used for the evaluation of this model. The analysis of the data for evaluation was conducted by an outside academic partner hired by HHH/SEARCH in collaboration with the HHD. The first three primary objectives (differences in depression and HRQoL) were assessed via the collection of client surveys every six months. Baseline assessments were collected prior to or during the first day of housing, with follow-up assessments collected by members of the service delivery team (e.g., CCM) approximately every six months after baseline. Participants received a $20 gift-card incentive at each assessment. Data Sources: Health Related Quality of Life (HRQoL) was assessed with the SF-36v2 is a validated tool, with demonstrated reliability (a = .78-.93) and validity among a variety of diverse populations, including those with chronic illness and substance use disorders. The SF-36 contains eight subscales: Physical Functioning (PF), Role-Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role-Emotional (RE), and Mental Health (MH). These subscales are combined into the Physical Component Summary (PCS) and the Mental Component Summary (MCS), with higher scores indicating increased HRQoL. Raw scores are transformed to norm-based scores, accounting for age and gender, on a scale of 0-100 using a T-score transformation to allow for comparisons with nationally representative samples. Mean changes in scores over time were compared to predetermined cut-off points as established through the literature to indicate a minimally important differences (MID). As opposed to relying on statistical significance scores which may not indicate a meaningful change in the participant's experience, MID indicate a clinically relevant change in the participant's score such that the participant would likely make note of the change and their clinical plan may be altered as a result. Depression was screened using the 9-item version of the Patient Health Questionnaire (PHQ-9). The PHQ-9 is a widely used measure that has been used effectively with older, homeless adults with good internal consistency in this sample (a =.86). Each item is scored from 0 to 3, with higher scores (0 to 27) indicating greater depression. Since the scale is additive, missing items were replaced with mean scale scores collected at that time point. The final objective was assessed using secondary data. Sociodemographic, housing and health data were attained through secondary data sources including the participant's 1) electronic health record (EHR) and 2) Homeless Management Information System (HMIS). Severe mental illness included all individuals who had a diagnosis of bipolar disorder, major depressive disorder, post-traumatic stress disorder or psychotic disorder. Emergency room (ER) use and service utilization was extracted from the EHR. For ER data, HHH shares an EHR with the local public health system which allows for good exchange of data within that system, but would miss any ER visits to hospitals or clinics who do not report health data into the shared EHR system. Analysis: Differences between those who exited PSH and those who remained housed were evaluated using Cox proportional hazards regression. To assess mean differences in outcomes at 6-month intervals, the data were stratified by group and within-person differences at each time point was compared to the baseline scores with a repeated measures ANOVA. To address multiplicity, The False Discovery Rate was controlled for using Benjamini and Hochberg's method in order to retain power. Changes in the outcomes over time were evaluated using hierarchical linear growth models with HLM v. 6.0. Growth curve modeling has advantages over traditional methods for analysis of repeated measures data, including allowance for missing data and unequal time intervals. Time-varying outcomes (MCS, PCS and PHQ-9 scores) are repeated measures at Level 1 nested within individuals at Level 2. Level 2 variables (i.e., individual differences and group assignment) were considered as predictors of time-varying growth of Level 1 outcomes variables. Time was entered as days from baseline, with the baseline set to 0 days. In order to explore different patterns of growth, common functional forms (linear, quadratic and cubic) were tested to identify whether a higher-order polynomial was a better fit of the data.34 Backwards elimination was conducted with the highest ordered polynomials simultaneously entered and eliminated if p<.05. The cubic model was not a good fit of the data and was eliminated for parsimony. At Level 1, the linear factor (Time) was retained to assess linear change in the outcomes over time relative to zero and the quadratic factor (Time²) to assess changes related to the rate of change over time. To assess predictors of Level 1 outcomes (MCS, PCS and PHQ-9), Level 2 dummy-coded sociodemographic characteristics including gender, race, ethnicity, mental illness, and insurance coverage were simultaneously entered into the model. Significant predictors were retained for the final model. In the final model, at Level 2, Group (0=Comparison, 1=HHH/SEARCH), Age (group centered) and Insurance (0=Uninsured, 1=Insured) were entered. The Time X Group interaction assessed differences between groups in their linear rate of change while the Time² X Group interaction assessed whether the rate of change differed between groups. To assess change in ER use over two years, individuals who were actively enrolled in the HHH/SEARCH group for two or more years at the time of data extraction from the EHR were included in the analyses. Results/Objectives: All four goals/ objectives were met through this service delivery model. This includes: Objective #1: Significantly and meaningfully increase the client's self-reported physical health-related quality of life as measured by the PCS subscale of the SF-36 The Physical Component Score (PCS) did not exceed the MID for either group until 30 months. At 30 months, the HHH/SEARCH group had exceeded the MID PCS score. Group status significantly predicted linear growth for PCS scores, with the HHH/SEARCH group reporting an increase in PCS scores [ p < .01] with a slower rate of deceleration over time [p < .05]. Objective #2: Significantly and meaningfully increase the client's self-reported mental health-related quality of life as measured by the MCS subscale of the SF-36 At 6 months, participants in neither group surpassed the minimally important differences (MID) on any SF-36 domain. At one year, both groups had exceeded the MID for Mental Component Score (MCS) (Table 3). For the HHH/SEARCH group, this improvement was sustained with participants reporting a MCS score that exceeded their baseline MCS score at each time point up to 30 months. For the comparison group, the MCS score only exceeded the MID at 12 months and then dropped below the MID in subsequent months. There was a significant linear increase in MCS scores with a negative quadratic decrease, indicating an accelerated initial increase in MCS scores with a deceleration of that increase over time. Group status significantly predicted linear growth in MCS scores, with the HHH/SEARCH group reporting an increase in MCS [p < .01] with a slower rate of deceleration over time [p < .05]. Objective #3: Significantly reduce the client's self-reported symptoms of depression over time as measured by the PHQ-9 Change in PHQ-9 scores over time were similar, with significant reductions in depression for only those in the HHH/SEARCH group. Similar to MCS scores, PHQ-9 scores had a negative linear slope paired with a positive quadratic slope. These results suggest that, not accounting for individual or group differences, HRQoL and PHQ-9 continuously improved after enrollment with the most rapid improvements reported shortly after housing/service enrollment. Group status was related to a linear decrease in PHQ-9 scores, with the HHH/SEARCH group reporting greater reductions in PHQ-9 scores over time relative to the comparison. Objective #4: Reduce client utilization of emergency rooms over two years. After two years, the total number of ER visits for the intervention group decreased by over 70%. Given that participants were required to report three ER visits in the two years prior to enrollment, it is possible that individuals were enrolled in a year of high ER use and that they would have reduced ER use over time regardless of the intervention. The impact of service delivery separate from housing could not be determined without comparison group data. Still, considering the cost of each ER visit, the reduction in expensive visits may indicate potential for cost-saving from a societal perspective.
Lessons learned in relation to practice: Over the years, the practice has continued to evolve. One way in which this has occurred is through engagement with the Behavioral Health Consultant (BHC). In earlier years, clients who wanted to meet with the BHC were required to make an appointment and attend that appointment at the Federally Qualified Health Center. In order to further reduce barriers to care, the BHC now visits with and follow-ups with a caseload of clients at the PSH site. A Licensed Chemical Dependency Counselor has also increased participation with on-site services. Another lesson learned is the key role that the on-site RN played in navigating care and serving as the liaison between the on-site staff and clinic staff. Lessons learned in relation to partner collaboration: The success of the service delivery model is contingent upon the success of the collaboration between partner organizations. The organization charged with clinical case management (SEARCH Homeless Services) and healthcare service delivery (Healthcare for the Homeless Houston) have a long history of successful partnership, eliminating potential friction that could otherwise occur when two agencies work together towards a shared goal. In order to facilitate collaboration between partners, the leadership and staff from both teams would meet bi-weekly to discuss questions or concerns related to the program or shared clients. Given the success of the model, the meetings were later moved to monthly. Cost/benefit analysis: We have conducted a preliminary cost-benefit analysis focused on emergency room utilization. This service delivery package is estimated to cost $8,000 per person per year. As stated in the ‘Evaluation Section' of this application, there was a 71.05% reduction in total ER use across participants enrolled in the intervention for 2 or more years (165 vs 570 ER visits). We are in the process of investigating data to conduct a more extensive cost-benefit analysis on all healthcare utilization prior to and after entering the program. The challenge is acquiring accurate data on healthcare utilization prior to enrollment in the service delivery model since most individuals were uninsured prior to entry and would not have associated claims data available. The HHD and partner organizations are working with academic collaborators to identify ways in which to resolve this issue moving forward. Stakeholder commitment to sustainability: Given the great promise demonstrated by this practice in increasing the health and wellbeing of those served, there have been discussions about continuing to support funding through partnerships with Medicaid managed care organizations (MCOs), which may be able to cover the cost of services for Medicaid members if there is a demonstration of cost-saving. We are currently in conversation with a number of MCOs about the possibility of continuing to support this model. We are in the process of collecting data to provide evidence of the potential for current and future cost saving. Another option is to support the service delivery models through other value-based purchasing models that support payment for outcomes as opposed to traditional fee-for-service payment models.
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