Training Outline b

A CHICAGO AREA SUPPORTIVE HOUSING COLLABORATIVE

Better Health Through Housing

Homeless: $233,000

Carlos after 9 months of supportive housing:$147,000

after 20 months: $ 86,000after 32 months: $ 69,000

Carlos

What is Better Health Through Housing?

Frequent Users System Engagement (FUSE)

Why?

26 (22 for singles) Agencies in Collaboration Negotiations Committee Steering Committee

Possible Managed Care Entities: IlliniCare, County Care, University of Illinois Hospital

Support from Michael Reese Health Trust

Better Health Through Housing Collaboration

Steering CommitteeNegotiations Committee

Center Staff

Triple Aim of the ACA

1) Improve population health

2) Enhance patient experience and health outcomes

3) Decrease costs

Benefits of Better Health Through Housing

Care Coordinators and Case Managers are able to work collaboratively towards client’s health needs

Stable housing for highly vulnerable population

More funds available for agencies to better serve our clients Negotiations for PMPM rate

Partnership with 22 agencies in Chicago area

May lead to more housing for clients in the future  

Introduction to the Center for Housing and Health and the AIDS Foundation of Chicago

The Center for Housing and Health promotes the coordination, research, evaluation and policy development of housing and health programs that serve vulnerable populations in the Chicago Metropolitan Area.

Center for Housing and Health

Supporting Organization of AFC created in 2011

Serving chronically ill homeless individuals and families, not exclusively those impacted by HIV/AIDS

CHH Team

Arturo Bendixen, Executive Director of CHHPeter Toepfer, Director of ProgramsJessie Beebe, Health Services SpecialistEllen Ryan, Outreach Services SpecialistAlice Wightman, Housing Services SpecialistMelanie Paul, Family Support Services SpecialistSarah Dyer, MSW InternSuzanne Lemaire Lozier, MSW InternTBD, Better Health Through Housing Project

Coordinator

Introduction to CCH & AFC

What is AFC? Advocacy- on behalf of people living with HIV/AIDS,

the homeless, and other marginalized populations Funding- to develop and sustain programs that serve

vulnerable populations Coordination- bringing together partner agencies to

provide standardized and quality services to clients

CHH & AFC Supportive Housing Programs

Based on collaboration and partnerships to end homelessness

Serve targeted homeless subpopulationsProvide a standard level of housing case

management regardless of programPromote Housing First and Harm Reduction

interventions

CHH Model of SHP

Chicago Housing for Health Partnership Study

CHHP4 year research project - RCTSeptember 2003 – December 2007405 participantsJAMA published outcomes in June 2008Study has become Hospital to Housing

Program

CHHP Study Results

Decreased nursing home daysDecreased inpatient hospital daysDecreased emergency room visits

SHP Participants are HEALTHIER

For every 100 chronically homeless individuals housed, there was a savings of almost $1 million in public funds

CHHP Study Results

Medicaid SHP

Health care costs decrease down drastically once someone is housed

31 High UsersYear Inpatient

Hospital

Outpatient Hospital

Nursing Homes

Physician Visits

Pharmacy Other Total

2011 $540,000 $64,000 $85,000 $98,000 $362,000 $81,000 $1,230,000

2012 $378,000 $76,000 $27,000 $103,000 $389,000 $73,000 $1,047,000

2013 $275,000 $47,000 $0 $88,000 $343,000 $59,000 $813,000

%

Decline

49% 27% 100% 10% 5% 27% 34%

Percent of Residents with Chronic Conditions

At least 1 med-ical condition

Diagnosed Substance Use

Disorder

Diagnosed Mental Health

Disorder

HIV Positive0%

20%

40%

60%

80%

100%

120%

Percent of Residents with Chronic Con-ditions

Multiple diagnosis for 31 High Users

With 2 chronic illnesses – 100%

With 3 chronic illnesses – 94%

With 4 chronic illnesses – 77%

With more than 4 chronic illnesses – 52%

Pre-Housing

Referral

Eligibility

Housing Search (30 Days)

HUD Definition of Homelessness

An individual or family who lacks fixed, regular and adequate nighttime residence, meaning: Sleeping in a place not meant for human habitation Living in a shelter Exiting an institution where they resided for less than

90 days if lived in shelter or place not meant for human habitation prior to entry

Aspects of Supportive Housing for FUSE Participants

Housing First

Harm-Reduction

Linkage to external services

Voluntary, client-centered services

What is Harm Reduction?

Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with high-risk behaviors. Harm Reduction strategies can be applied to a variety of issues, including drug or alcohol use, mental health, physical health, housing, domestic violence, etc.

Harm reduction incorporates a spectrum of strategies aimed at meeting people “where they’re at” in order to offer respectful, individualized interventions to assist people in reducing risk in their lives

Why take a Harm Reduction Approach?

Harm-reduction is an approach that can be used to engage participants in a non-judgmental, collaborative discussion about risk reduction and increased health and safety

People are inherently more likely to make changes in their lives if they believe that making a change is necessary and they feel motivated to do so

Operating from a harm-reduction approach allows case managers to use creative strategies to keep our participants housed and prevents a return to homelessness, while allowing our participants to maintain self-determination

Ongoing Housing Case Management Services

Data Gathering/Reporting

Systems Integration Team (SIT) Meetings

Communication with Pilot CoordinatorCommunication with Care Coordinator

Critical Time Intervention (CTI) for Newly Housed Participants

Level of Contact

Data and Reporting

CHH is responsible for reporting data to MCEs

CMs are responsible for sharing monthly contact and services provided form

Systems Integration Team (SIT)

CollaborationCommunicationOutreach and

housing staff attend

Bi-weekly meetings

Trouble shooting and brainstorming

Support

CTI: The Model

Critical Time Intervention (CTI) is a time-limited approach (9 months) focused on ensuring housing retention and connections to community supports.

The CTI model includes three 3-month phases of case management services, with decreasing intensity of case manager involvement as participants gain stability.

CTI is an evidence-based practice.

CTI: The Model

The principle goal of CTI is to prevent recurring homelessness and other adverse outcomes during the initial period of placement into housing & the community

Two main ways the model achieves this:Strengthening the individual’s long-term ties

to services, family and other social supportsProviding emotional and practical support

during the “critical time” of transition

Key Components of CTI

- Services are provided in the home and community

- On-going assessment of and addressing housing barriers; focus on eviction prevention

- Connection to other mainstream and community-based services, including mainstream benefits

- Connection to natural supports, including family, friends and spiritual support

- Use of evidence-based practices, including Motivational Interviewing, person-centered service planning, trauma informed care

The CTI Model

Three Phases:Phase I: Transition to Housing & Community (first 3 months)Phase II: “Try Out” (months 4-6)Phase III: Step-down (months 7-9)

Phase I: Transition to Housing & Community

- Time period: Referral stage and first three months of housing

- Goal: Provide as much support as possible & implement “transition” plan (from homelessness to housing)

Phase I: Case Manager Responsibilities

- Assess for housing and other needs- Accompany participant to view units & assist with apartment

set-up- Provide home visits a minimum of once weekly, more

frequently if necessary- Review of terms of the lease and tenancy skills is provided

regularly in detail- Maintain frequent contact with all of participant’s services,

supports & landlord- Address immediate issues that affect housing- Address crisis, as-needed- Begin planning to assist participant with maintenance of

long-term supports and services- Encourage a focus on purpose and activity

Phase II: Try Out

- Time period: Months 4-6 of housing- Goal: Facilitate and test participant’s problem-solving skills- Contact: At least two home visits per month, depending on

resident need- Monthly contact with participant’s service providers and

landlord

- Signs of readiness for transition to Phase II: The participant is experiencing less crisis The participant has something to do during the day The participant maintains strong communication with services,

supports & landlord; is able to access supports independently Supports are in place to address housing issues, including rent

payment, conflict management with landlord/neighbors and apartment maintenance

Phase III: Step-down

- Time period: Months 7-9 of housing- Goal: Transition from CTI services into appropriate level

of service- Contact: At least one monthly home visit with participant

- Monthly contact with participant’s service providers, supports & landlord

- Signs of readiness for transition to Phase III: Crisis is stabilized & participant has a plan in place for immediate

needs There is a plan in place to address barriers to housing retention as

issues arise Participant maintains regular communication with resources

Health Insurance

Expanded Medicaid Eligibility

Changes to Medicaid Eligibility With the implementation of the Affordable Care Act, many

more individuals in Illinois are now eligible to receive Medicaid, unless they are undocumented

Eligibility for Medicaid now includes individuals who earn less than 138% of the poverty level (approximately $16,000 for an individual), have US citizenship, are adults between ages 19-64

CountyCare – Cook County received permission from the federal government to enroll individuals in Medicaid early (2013).

Managed Care/Care Coordination Enrollment

Legislative Mandate to Implement Coordinated Care Initiatives

Put at least 50% of Illinois Medicaid recipients in a “Care Coordination/Managed Care” program by January 2015

• ICP – Integrated Care Program (Older Adults and Disabled AABD only)• MMAI – Medicare Medicaid Alignment Initiative (Dual Eligible)• MCE – Managed Care Entity (Umbrella Term for CCE, MCCN,

MCO/HMO, ACE)• CCE – Care Coordination Entity (Target Populations)• MCCN – Managed Care Community Network• MCO/HMO – Managed Care Organization/Health Maintenance

Organization• ACE – Accountable Care Entity (called Accountable Care Organization

(ACO) in other states)• CCMN - Children with Complex Medical Needs

Why? Improving Health and Reducing Cost of Care for High-Utilizers

• Spending more – getting less. Illinois Medicaid Program costs growing quickly but Medicaid recipients’ health not improving or in some cases getting worse.

• According to HFS, 16% of Medicaid recipients who are Seniors and Persons with Disabilities (SPD) cost 55% of the Medicaid budget (for all agencies).

• HFS’ stated goal is to create integrated delivery systems that provide quality care and result in better health outcomes for Illinois Medicaid recipients at reduced costs.

Four main ways people can get on Medicaid in IL

“Seniors & People with a Disability”

Low-income adults who are totally disabled with

no work history

“Dual Eligibles”Low-income adults who are totally disabled who

have a work history

“New eligibles”, “ACA eligibles”

Low-income adults age 19-64 who are not

disabled and do not have children in the home

(CountyCare)

“Parents/Caretakers”*Low-income parents or caretakers who have

children in their home

What is care coordination?

Care coordination is a multifaceted process wherein a team takes responsibility for coordinating medical and social support services for high-risk populations across different providers and organizations.

Care coordination team members coordinate—rather than provide—care, and will often leverage technology such as health information exchanges

Example: Your participant goes to the hospital or ER for an emergency. The care coordination team might follow up with your participant asking them about follow up care with a PCP and medication refills. If they are having trouble scheduling an appointment or getting refills the care coordinator will help them accomplish these tasks.

Managed Care Entities

Family Health Plans/Affordable Care Act Health Plans (FHP/ACA):

Aetna BCBS CountyCare IlliniCare

Meridian

Accountable Care Entities (ACEs)

Advocate Accountable Care Better Health Network Community Care Partners HealthCura Loyola Family Care MyCare Chicago SmartPlan Choices UI Health Plus

Integrated Care Program (ICP):  • Aetna Better Health • Blue Cross Blue Shield • Cigna-HealthSpring • Humana • IlliniCare• Meridian  Care Coordination Entities (CCEs)  • Be Well (certain zip codes)• CountyCare • Entire Care • Medical Home Network • Next Level • Together4Health

Talking with participants: Care coordination/managed care education

Concrete, specific and relevant examples about how care coordination/managed care will impact and improve their care

Opportunity to talk about how the health care system is changing for the better – what steps the client can take to improve their health and take advantage of system changes

Questions from clients – will I have to switch doctors? do I have to leave any of my programs? General concerns about change.

Try to focus on positive aspects of change, emphasis the support that will be available to help adjust to changes

Role of case managers in health care engagement

Encourage participants to take advantage of health care changes

Ask about consistent, routine visits with PCP or other providers Ongoing assessment of challenges or barriers

Prompt participants to follow-up with referral appointments

Assist with locating a convenient pharmacy and setting up a schedule for medication pick-up to avoid missed refills

Include discussions about health care in routine case management services

How does my role as a case manager fit in with care coordination?

Much of what you’re already doing supports care coordination

Individuals from a care coordination team might need your help to contact a participant or gather information about the participants health care needs

Your participants should be aware that the care coordination team is working with case managers, the participant and other members of the participant’s care team to improve their health

An increased focus on health and health outcomes

Education on insurance, care coordination/managed care, utilizing primary care

Encourage participants to take advantage of care coordination

Questions?