Network Coordinates Housing and Medical Services for Disabled and Chronically Ill Adults
From July 1995 through June 1998, the Corporation for Supportive Housing (CSH) in Oakland, Calif., developed the Health, Housing and Integrated Services Network, which brought together more than 30 public and private nonprofit agencies. Their goal was to integrate social, health, mental health and housing services for formerly homeless adults and those with very low-incomes who also had mental illness, HIV/AIDS, other chronic illnesses and/or a history of substance abuse.
The project was part of the Robert Wood Johnson Foundation (RWJF) national program, Building Health Systems for People With Chronic Conditions.
- The collaborating organizations developed 10 interdisciplinary teams that delivered primary health care, client-centered treatment for mental illness and substance abuse and other health and support services (including employment opportunities), all linked to stable, affordable housing.
- By 1999, the interdisciplinary teams had provided services to almost 1,000 people living in more than 900 units of affordable housing in San Francisco and neighboring Alameda and Contra Costa Counties.
- In a post-grant study, researchers from the University of California at Berkeley found that residents had a 58 percent decline in emergency department use, a 57 percent reduction in hospital inpatient days and virtually no use of residential mental health care outside hospitals.
- Policy barriers and a lack of readiness and administrative capacity among many of the organizations participating in the network prevented the project from meeting its expectation of establishing risk-adjusted capitation rates to finance managed care services through the network.
RWJF provided a $740,001 grant for the initiative.
As state and county health departments in California were establishing managed care programs for Medicaid beneficiaries in the early 1990s, they realized that especially high users of health services-disabled adults with chronic health problems such as mental illness, HIV/AIDS and/or substance abuse-would have to be enrolled in managed care in order for reform and cost-containment efforts to be successful.
This subset of disabled adults is often homeless, and cycles repeatedly through high-cost health care delivery sites, such as the psychiatric emergency units and emergency departments of public hospitals, jails and inpatient units. In these locations they receive costly but ultimately ineffective care. The frequent use of episodic emergency care reflects:
- The limited access to primary or preventive care services.
- The compartmentalization of necessary health services.
- The failure to link those services to housing.
RWJF's Support of the Corporation for Supportive Housing (CSH)
The national nonprofit Corporation for Supportive Housing (CSH), which was established in 1991 to expand the availability of permanent, service-enriched housing for homeless and at-risk individuals, had been addressing this problem in several states with support from RWJF (see Grant Results on ID#s 018047, 019309 and PC332 and on ID# 021883) and a wide range of other funders.
Its approach was to construct and operate supportive housing that offered health and social services to people suffering from chronic health problems, such as alcoholism, substance abuse, mental illness or HIV/AIDS.
This project was designed to develop a unique and replicable model for creating a network of public and private agencies to deliver and finance integrated housing, health care and social services in San Francisco and neighboring Alameda and Contra Costa Counties.
The target population consisted of formerly homeless adults and those with very low-incomes who also had mental illness, HIV/AIDS, other chronic illnesses and/or a history of substance abuse. The network would serve this population by bringing together landlords and health care and social service providers that worked in the fields of primary health care, mental health and substance abuse treatment and specialty care. These providers often serve the same consumers, but rarely work in an integrated, coordinated fashion.
The project's specific objectives were to:
- Provide integrated, flexible services.
- Establish appropriate, risk-adjusted capitation rates.
- Reduce the limitations of categorical funding (i.e., funding restricted to specific programs, which sometimes limits the coordination and integration of multiple programs).
- Document the cost effectiveness of the intervention.
Project staff worked at two levels:
- The program level, to enhance integrated service delivery capacity by establishing multidisciplinary integrated service teams linked to housing.
- The system level, to develop the core administrative systems, provider "network" governance structure and data needed to provide a comprehensive array of health care and related services.
Project staff published four reports on the project, along with a book chapter and an article in Current Issues in Public Health. The report, entitled Supportive Housing and its Impact on the Public Health Crisis of Homelessness, was cited in a front-page article in the San Francisco Examiner. In September 2000, project staff made a presentation at a meeting sponsored by the U.S. Department of Health and Human Services, entitled Building Partnerships for Access to Health Care and Services for Persons Who Are Homeless. They conducted a series of project-related workshops for Health, Housing and Integrated Services Network participants and made numerous presentations. Additional information concerning the project can be found at CSH's Web site. (See the Bibliography for details.)
Other funders were:
- The U.S. Department of Housing and Urban Development's (HUD) Supportive Housing program ($4 million).
- San Francisco Department of Public Health (approximately $300,000 annually).
- The California Endowment ($1 million).
- The Rockefeller Foundation ($1 million).
- HUD's Regional Innovative Homelessness Initiative ($979,000).
- Blue Cross California Health Care Partnerships Program ($200,000).
- The Henry J. Kaiser Family Foundation (approximately $40,000).
- Kaiser Permanente Medical Center ($5,000).
- Project staff established the Health, Housing and Integrated Services Network, a provider network of more than 30 public and private nonprofit health care, mental health, social service and housing providers that collaborate to fund and deliver affordable housing and a full range of health and support services to consumers.
- CSH established 10 Health, Housing and Integrated Services Network Integrated Services Teams to provide services linked to permanent housing for people who had been homeless and disabled by mental illness or other chronic health conditions, in San Francisco, Alameda and Contra Costa Counties. By 1999, nearly 1,000 individuals in more than 900 units of affordable housing had obtained services from these network teams. While the staffing model for each team varies based on the needs of consumers at each site and the availability of resources in each community, a Health, Housing and Integrated Services Network Integrated Services Team typically offers:
- Primary medical care delivered on site at least once a week by a mid-level practitioner or physician who also can see clients at a nearby full-service primary care clinic if needed.
- A licensed clinical social worker and other professional staff with strong clinical skills and linkages to mental health and substance abuse treatment services.
- Peer support from at least one team member who has personal experience with homelessness, mental illness, recovery from drug or alcohol addiction, or HIV/AIDS.
- Vocational, pre-employment and employment services.
- Service coordination to facilitate effective teamwork with property management to prevent crises and intervene quickly to prevent loss of housing for residents.
- Community-building, social and recreational activities.
- Money management counseling.
- CSH worked with housing and mental health service providers to implement new services based on the network model in San Mateo, Santa Clara, Marin and Contra Costa Counties. This expansion brought the total number of unduplicated clients served by the network to more than 1,000 by the end of 1998.
- CSH served as a fiscal intermediary, applying for and receiving funds on behalf of the service providers, collecting data and insuring proper reporting. This made it easier to draw on funding sources that often have categorical funding limitations.
- CSH established a policy advisory group, comprised of local government officials, funders of the network, and service providers. CSH looked for funding options and strategies to support the network when existing demonstration project funds ended.
- The California Association of Health Plans (a trade association representing virtually all of the licensed plans providing health coverage to more than 20 million Californians) awarded the 1998 Health Net Health Promotion award to CSH. The award was bestowed "in recognition of the corporation's outstanding efforts to assist homeless persons through effective integration of housing and health care services."
- Residents in the housing units supported by the network had a 58 percent decline in emergency department use, a 57 percent reduction in hospital inpatient days and virtually no use of residential mental health care outside hospitals, according to a post-grant study by researchers from the University of California at Berkeley. The study compiled medical health care data on 253 residents from two supportive housing units, and mental health care data on a smaller subset of those residents, between 1992 and March 2000.
- CSH was unable to establish risk-adjusted capitation rates to finance managed care services. The grantee's inability to accomplish this objective during the grant period reflected both policy barriers and a lack of readiness or administrative capacity among many of the Health, Housing and Integrated Services Network participant organizations.
Project staff published four reports on the project, along with a book chapter and an article in Current Issues in Public Health. The report entitled Supportive Housing and its Impact on the Public Health Crisis of Homelessness was cited in a front-page article in the San Francisco Examiner.
In September 2000, project staff made a presentation at a meeting sponsored by the U.S. Department of Health and Human Services, entitled Building Partnerships for Access to Health Care and Services for Persons Who Are Homeless. They conducted a series of project-related workshops for Health, Housing and Integrated Services Network participants and made numerous presentations.
The grantee's efforts to develop a provider network to serve high-risk participants required working with the involved agencies to address a range of institutional change strategies. Among the lessons learned as part of that process:
- Creating effective interagency partnerships to deliver services requires more ongoing assistance than anticipated. CSH had originally conceptualized its role as creating new financing and administrative systems and integrating existing services but instead found it necessary to assume greater responsibility for managing the performance and building the capacity of project partners. Effective supervision, adequate training for direct service staff and ongoing coordination among supervisory staff is essential to prevent the vision of integrated services i.e., "shared responsibility" from being translated into "someone else's responsibility." (Project Director)
- Organizations may need to modify their treatment strategies and policies for serving people with chronic substance abuse problems. Providing services for this hard-to-serve population, many of whom are seriously mentally ill, requires creative, client-centered engagement strategies and the ability to build trusting relationships among team members. (Project Director)
- Collaborating to deliver services requires changes in the role of skilled clinicians and new ways to measure productivity. Medical staff who are accustomed to busy clinical practices can find it difficult to adapt to working as a member of an interdisciplinary team in which care management requires a commitment to participating in formal and informal meetings and receiving input from peer and paraprofessional staff as well as other skilled clinicians. (Project Director)
- Public agencies working as part of an interagency network must learn to adapt to the needs of other providers. Public health departments face a different set of constraints than nonprofit agencies, including political oversight, bureaucracy and a civil service workforce with rigid hiring procedures and work rules. In general, the Health, Housing and Integrated Services Network represented a new approach to accountability, shared decision-making and resource allocation. (Project Director)
- Accountability for comprehensive services and managed care outcomes required many providers to make substantial changes in their organizational capacity and practice. Some partners had well-established systems for tracking client demographics, clinical needs and service interventions. Other network service partners had to consider substantial changes to develop appropriate capacity. It was particularly challenging to develop forms, procedures and management information systems that are appropriate for use in the permanent housing setting in which services are being provided. (Project Director)
AFTER THE GRANT
CSH continues to disseminate its results and approach. At the end of 1998, the group began working with California's Department of Mental Health to implement a state Supportive Housing Demonstration Project incorporating many of the strategies developed by the Health, Housing and Integrated Services Network project.
Over the next year, 13 California counties were selected to receive funding to establish or expand services as part of the demonstration project. CSH and its network partners began working with other stakeholders to establish a consensus regarding the need for federal policy changes that would support integrated services and the investment of mainstream resources in meeting the needs of people with serious mental illness or other chronic health conditions who are homeless or at risk of homelessness.
RWJF has continued to support CSH with a series of grants to develop housing to combat long-term homelessness, mainly through the following programs:
- Taking Health Care Home: A National Initiative to Reduce Chronic Homelessness through the Creation of Supportive Housing. This project is at the heart of RWJF's effort to reduce chronic homelessness in major urban areas over the next decade (200616). This effort is now part of a larger collaboration of private and public funders to make supportive housing a viable and integral component of the urban safety net. This project represents the culmination of 20 years of RWJF investments to develop and refine the supportive housing model. $12,012,050. ID#s 043050 and 051162. August 2002 to January 2007.
- Establishing Supportive Housing as an Essential Component of Reintegrating Ex-offenders into Communities. This project advances the concept of re-entry supportive housing as a core component of community-wide strategies targeting individuals leaving or at risk of returning to prison and jail.
Each year, more than 600,000 individuals are released from prison and more than 7 million are released from jail. They typically return to impoverished communities facing significant barriers to reintegration. Co-occurring and untreated mental and physical health conditions within this group frequently lead to behaviors that prompt community complaints resulting in police intervention, re-arrest, and re-incarceration.
These individuals also represent the most frequent and highest cost users of both corrections and safety-net institutions (hospitals, clinics, shelters and public agencies). $6 million, ID# 053461, February 2006-February 2009.
GRANT DETAILS & CONTACT INFORMATION
Development of an Integrated Housing, Health and Supportive Services Network for Disabled Adults
Corporation for Supportive Housing (Oakland, CA)
Dates: July 1995 to June 1998
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Culhane D, Eldridge D, Rosenheck R and Wilkins C. "Making Homelessness Programs Accountable to Consumers, Funders and the Public." In Practical Lessons: The 1998 National Symposium on Homelessness Research. Linda Fosburg and Deborah Dennis (eds.). Washington: U.S. Department of Housing and Urban Development & U.S. Department of Health and Human Services, 1999.
Wilkins CL. "Building a Model Managed Care System for Homeless Adults with Special Needs: The Health, Housing and Integrated Services Network." Current Issues in Public Health, 2(Spring): 3946, 1996.
The Network: Health, Housing and Integrated Services. New York: Corporation for Supportive Housing, 1997 (updated in 1998).
Turning Homelessness Around: Restructure Mainstream Systems; Integrate Homeless Specific Responses; Lessons Emerging from the Successful Strategies of the Bay Area Regional Initiative. New York: Corporation for Supportive Housing, 1999.
The Network: Health, Housing and Integrated Services, Best Practices and Lessons Learned. New York: Corporation for Supportive Housing, 2000.
Supportive Housing and Its Impact on the Public Health Crisis of Homelessness. New York: Corporation for Supportive Housing, 2000.
World Wide Web Sites
www.csh.org. The Corporation for Supportive Housing maintains information regarding the Health, Housing and Integrated Services Network at this site. New York: Corporation for Supportive Housing.
Report prepared by: Robert Crum
Reviewed by: Karyn Feiden
Reviewed by: Molly McKaughan
Program Officer: Rosemary Gibson
Program Officer: Jane Isaacs Lowe