training outline b
TRANSCRIPT
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?