Enhanced Supportive Housing as an Alternative to Skilled Nursing Facility Care- Guest blog by Joshua Bamberger

Joshua Bamberger, MD, MPH,  is the Associate Clinical Professor Family and Community Medicine, UCSF and Chief Medical Consultant for Mercy Housing

In San Francisco, the Department of Public Health has invested heavily in permanent supportive housing using local government funds.  The Direct Access to Housing program of SF DPH opened its first master leased, renovated single room occupancy hotel in January 1999 providing permanent supportive housing for 86 formerly homeless adults.  Since then there has been a rapid expansion of housing with approximately 150 new units being developed annually resulting in 1700 units of housing for homeless adults with a majority of units in new construction apartment buildings designed specifically to serve adults with a history of mental illness, substance use and chronic medical problems.  With the expansion of access to health insurance in the majority of states in the United States following the roll-out of the Affordable Care Act, there is increased interest in evaluating the DAH program to assess if supportive housing can help to achieve CMS’s Triple Aim (reduced cost, improved measurable outcomes, improved patient experience).  In collaboration with CSH, Tenderloin Neighborhood Development Corporation and the NYU School of Public Health, the SF DPH is evaluating a random assignment trial of permanent supportive housing targeting chronically homeless adults.  Now in its second year, we continue to collect data with the hope of reporting preliminary outcomes in the next 12 months.  Outcomes to be measured include housing stability, mortality, tenant satisfaction and change in healthcare status and cost.

Permanent supportive housing has also been proposed as a cost effective alternative to long-term care in a skilled nursing facility (SNF).  Enhanced supportive housing that includes high quality architecture, on-site nursing and/or adult day health care and robust case management can provide a clinically appropriate alternative for some formerly homeless seniors at a fraction of the cost.  However, the health reimbursement system in the US has been hesitant to invest in permanent supportive housing as an alternative to SNF care in part because of the restrictions on how Medicaid funds can be used and because the long term return on investment has rarely  been reported.  This is despite the fact that interpretation of the American for Disabilities Act in the Olmstead decision requires that governments offer the least restrictive housing environment for all people with disabilities.  In a recent manuscript published by the San Francisco Federal Reserve Bank[1], we report on the healthcare utilization for a group of 51 formerly homeless seniors (over the age of 61) placed at a Mercy Housing’s Mission Creek Apartment.  Mission Creek is located adjacent to San Francisco’s professional baseball stadium overlooking San Francisco Bay.  In addition to providing permanent supportive housing for 51 formerly homeless seniors, it provides housing for 77 low income seniors with rental support from HUD’s Housing Choice program (formerly Section 8) and 11 units for seniors living with HIV through HUD’s funded from the HOPWA program.    In this study, we report on the housing stability and healthcare utilization for the 51 formerly homeless seniors over the past seven years since Mission Creek opened its doors in 2006.

Homeless seniors placed in Mission Creek had a dramatic reduction in hospital and SNF costs after placement.  In fact, the total cost for hospital and SNF care among these 51 seniors in the seven years since opening the facility was less than the hospital and SNF costs in just the one year prior to entering the housing.   An estimated 16,433 days of SNF care was avoided by placing the 12 seniors who moved directly from a SNF into enhanced supportive housing at Mission Creek.  The estimated cost avoided by having these 12 formerly homeless adults exit the SNF was greater than the total cost of on-site services, rental subsidy and hospital based care for all 51 seniors placed in the facility over the past 7 years.

This small study adds to the ever expanding body of work that documents the economic value of placing long-term, frail homeless adults into permanent supportive housing.  Local healthcare systems that are finding ways to use healthcare dollars to guarantee access to and continue support of on-going costs of enhanced permanent supportive housing will be able to provide a cost effective treatment for the conditions that often bring seniors to homelessness in the first place and be able to do so at considerable less expense than paying for a skilled nursing facility.  Achieving the two most scrutinized components of the triple aims (reducing cost and improving outcomes) is a great accomplishment but achieving the last component of the triple aims- improving patient experience- is why many of us have committed our careers to serving chronically homeless adults.  As one man placed from San Francisco’s Healthcare for the Homeless clinic reported when he moved into Mission Creek, “I try to play the lottery every week but I never win.  Now that I live in Mission Creek, I am finally a big winner.”

The fear that healthcare dollars will be used to solve all societies’ social ills is a reasonable concern.  However, framing housing as a medical treatment for a narrow, targeted subset of the population who are living with chronic medical and psychiatric conditions can help to assuage these fears.  As the homeless population ages, the need to provide less expensive alternatives to skilled nursing facilities will only continue to grow.  Enhanced, permanent supportive housing can meet that need and, if used judiciously, can contain healthcare costs and the size of government.  Mission Creek Apartments in one example that hopefully will entice large healthcare delivery agencies such as United Healthcare, Aetna and Kaiser to come to the table to pay for access to and services in housing to assure cost containment and improved quality of care for their members.

[1] http://www.frbsf.org/community-development/publications/working-papers/2014/july/long-term-cost-effectiveness-homeless-seniors-permanent-supportive-housing/

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