Addressing Homelessness Among People With Justice Involvement: Los Angeles County’s Just in Reach Pay for Success Demonstration Project

Article published in Cityscape.

Stephanie Mercier at CSH and Sarah B. Hunter and RAND Corporation co-authored an article in Cityscape, a journal covering research on housing and community development, published by the Office of Policy Development and Research (PD&R) of the U.S. Department of Housing and Urban Development. This article presents an overview of the execution and results of the inaugural Pay for Success (PFS) initiative with Los Angeles County. In 2017, the county embarked on a program utilizing the PFS framework that offered housing and supportive services as a jail alternative for those with a history of homelessness and persistent health ailments. This innovative model established a financing mechanism of two key investors, paired with funding collaborators, an intermediary team overseeing implementation and outcome benchmarks that included CSH, and an independent evaluator to assess the program's overall impact. The county collaborated with providers of housing rental assistance, service navigation, and intensive case management to administer the program. Participants were tracked over two years after enrollment and placement into supportive housing. Concurrently, the team followed the trends among a comparative cohort of similar individuals who were not program beneficiaries. This article summarizes how the program operated and was financed, what the findings were, and the broader evaluative implications. Its purpose is to spotlight how Los Angeles County applied the PFS approach to furnish supportive housing for those entangled with the justice system.

2023 FY Spending Bill and the Medicaid Unwinding: Implications for the Supportive Housing Community

Congress passed an FY 2023 spending bill that disentangled the Medicaid coverage protections from the the COVID-19 public health emergency (PHE). This law required states to begin processing Medicaid redeterminations by March 31, 2023. Redetermination is the process by which state Medicaid offices determine the eligibility of continuing Medicaid health care coverage for current enrollees. States that have expanded Medicaid allow Medicaid eligibility due to low income. States that have not expanded Medicaid require proof of low income AND another individual characteristic such as age, disability, and illness. This fact sheet describes how supportive housing programs should prepare for Medicaid redeterminations, by March 31, 2023 in all 50 states.

Summary of State Actions: Medicaid and Justice-Involved Populations

Persons who return to the community after experiencing incarceration face many challenges. Addressing basic needs like food, clothing, and shelter is likely their priority, as many do not have a home to which they can return upon discharge. Even for those who receive family support, it is challenging to navigate the process of obtaining and maintaining the services they need to thrive in the community. To end this inequity, we must provide healthcare coverage, such as Medicaid or Medicare, to people leaving prisons to ensure they have access to life-saving healthcare and medications. Still, few go with healthcare coverage on the day of release, and those who do tend to be persons who have had very short incarcerations, measured in days, not months or years. Depending upon the length of imprisonment, most individuals' benefits like healthcare coverage and food assistance are suspended or terminated upon incarceration. Upon release from incarceration, returning citizens must work to have benefits reinstated with discharge paperwork. This process alone is a barrier.

Recognizing this challenge, various states are requesting that the Centers for Medicare & Medicaid Services (CMS) allow the usage of 1115 research and demonstration waivers so they can facilitate the eligibility of Medicaid for justice-involved persons. If implemented effectively and by engaging people with lived experience (PLE) and cross-sector partners (criminal justice partners, primary care providers, pharmacy, housing options, etc.), these strategies can support continuity of care, improve health equity, decrease costs and prevent recidivism.

The report below highlights the actions states and other entities have taken or are requesting to take to allow benefit activation before people return to their communities after release from long-term incarceration

New Initiative in Kansas City Successfully Reduces Hospital Interactions and Promotes Housing Stability for Formerly Homeless Individuals

In 2017 Truman Medical Centers Behavioral Health, now known as University Health Behavioral Health, or UHBH, launched the 500 in Five campaign that committed to developing and/or securing 500 units of
housing over five years.

In partnership with University Health Behavioral Health (UHBH) staff, the Corporation for Supportive Housing (CSH) and University of Missouri – Kansas City (UMKC) Department of Psychology reviewed health care utilization, behavioral health services, and court data on 80 supportive housing tenants housed through the 500 in Five housing initiative launched
by UHBH in late 2017. The study group included people housed by UHBH between November 1, 2017, and February 25, 2020, a timeframe that allowed one year after housing elapses for each person before initiating a comprehensive records review of University Health (UH) health care utilization among these individuals in April 2021. The purpose of the analysis was to see what effect if any, housing had on tenants’/patients’ utilization of UH health care services and UHBH outpatient services.

The data presented in this report suggest that enrollment in UHBH’s behavioral health services combined with subsidized housing had a significant effect on how patients utilized health care at the hospital. Looking at utilization by subtype group yielded several statistically significant results that demonstrated changes in health utilization from pre-housing to post-housing. Most notably, there was a steep decline in both the number of psychiatric inpatient events (down to less than one on average per person from nearly five in the pre-period for those psychiatrically hospitalized in the year prior to housing) and the cost of those hospitalizations (decreased by 98%).

This result is consistent with several studies of permanent supportive housing that show significant decreases in psychiatric emergency department visits and psychiatric inpatient hospitalizations.

7 Strategies to Engage the Health Sector and Advance Supportive Housing 

The 2022 CSH Health Strategy presents seven strategies for the supportive housing field’s engagement with the health sector. Based on the CSH work around racial equity and our Racial Disparities and Disproportionality Index (RDDI), these strategies are timely and address opportunities that communities can take now to maximize impact. We understand that every community has different needs, and a different policy and political context and while not every strategy may apply to all communities, every community can benefit from focusing on at least one of these strategies.

As the supportive housing movement leaders, our role is to guide and support the field and increase engagement with partners from the health care sector.

Focusing on Structural Racism To Address Social Determinants of Health

The concept of social determinants of health (SDOH) is rooted in an understanding that the conditions that people are born into (and live in) shape their health. It is essential that efforts to improve patient health must address not only medical care, but physical environment, social and economic needs, health behaviors, and other factors.


Structural racism is a primary driver of inequities in the conditions in which people of color are born and live, therefore all work to improve health by addressing SDOH requires an explicit focus on addressing structural racism and mitigating its impact on patients. This paper will provide examples of how structural racism in housing has affected inequities in SDOH and health outcomes.


Recommendations and community examples highlight how health and housing partners can work together to address health inequities are driven by structural racism.

Health and Housing: Introduction to Cross-Sector Collaboration (via NASHP)

This article was authored by Marcella Maguire, Allie Atkeson, and Sandra Wilkniss. Dr. Maguire is Director, Health Systems Integration at CSH. Below is an excerpt and link to the article.

For the past decade or more, state leaders have worked across health and housing sectors to strengthen comprehensive services for individuals experiencing homelessness and housing instability. However, challenges remain for successful, person-centered coordination, cross-agency work and implementation. A significant restricting factor that limits coordination is the fragmentation of the health and housing sectors, with persons or households with multiple needs having to navigate multiple systems to address these needs.

The COVID-19 pandemic and related economic and social crises have further exacerbated long-standing needs for coordinated health and housing services. Structural and institutional racism has created segregated communities and limited access to resources, furthering the need to center equity in states’ health and housing work. Click here to access the entire article.

Addressing the Opioid Crisis Series - Session #3 Innovative Programming and Partnering for People Experiencing Opioid Addiction

Session 3 in the Addressing the Opioid Crisis Webinar Series - Adequately serving patients with substance use disorder (SUD) and/or behavioral health needs requires proper coordination and partnership among multiple sectors and systems of social service. This webinar and facilitated panel discussion outlines best practices for building or improving upon such partnerships to better serve SUD patients served by health centers.

Addressing the Opioid Crisis - Session #2 State Responses to the National Opioid Crisis

Session 2 in the Addressing the Opioid Crisis Webinar Series - Adequately serving patients with substance use disorder (SUD) and/or behavioral health needs requires proper coordination and partnership among multiple sectors and systems of social service. This webinar and facilitated panel discussion outlines potential state-level responses to better serve SUD patients served by health centers.

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