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US San Diego, California, Seeks to Save Money by Helping Chronically Homeless

08:50  06 june  2018
08:50  06 june  2018 Source:   usnews.com

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San Diego County is seeking to streamline services for one of America’s largest homeless populations, and to save money in the process. In San Diego County, more than 2,000 people are chronically homeless , according to the point-in-time report, meaning they have a disabling condition

The City works partners with the San Diego Housing Commission to provide a continuum of care for episodic, transitional, and chronic The Housing Commission administers the City's homeless services and shelters programs based upon a memorandum of understanding between the City and

A homeless woman walks with her belongings in the East Village area of downtown San Diego, Calif., on Tuesday, Sept. 26, 2017.: A homeless woman walks with her belongings in downtown San Diego, Calif., in September 2017. © (Sandy Huffaker/The Washington Post/Getty Images) A homeless woman walks with her belongings in downtown San Diego, Calif., in September 2017.

San Diego County is relying on data to serve more than 1,000 of its neediest residents, and hopes to save millions of dollars in the process.

Nearly 8,600 people in the county of more than 3 million residents are homeless, more than half living within the city of San Diego, according to the county's 2018 point-in-time report conducted in January. Only New York City, Los Angeles County and King County, which encompasses Seattle, had larger homeless populations in 2017, according to the U.S. Department of Housing and Urban Development, and a recent poll showed 60 percent of respondents think San Diego's homelessness problem is getting worse.

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People who are chronically homeless have experienced homelessness for at least a year – or repeatedly – while struggling with a disabling condition such as a serious mental illness, substance use disorder, or physical disability. How Many People Experience Chronic Homelessness ?

Homeless by trolley tracks between San Diego Convention Center and Petco Park. They help families with children, single women, and single men including chronically homeless individuals, veterans Make Change Count meters in downtown San Diego raise money to help the homeless .

In San Diego County, more than 2,000 people are chronically homeless, according to the point-in-time report, meaning they have a disabling condition such as a substance abuse disorder or serious mental illness and have been homeless for a stretch or stretches totaling at least a year.

The chronically homeless tend to show up in emergency rooms, jails and shelters more often than those who lose their homes because of a job loss, surprise medical bill or another economic shock, leading to expenses for public and private agencies that amount to millions of dollars.

"We've got these larger economic and social forces going on. The people who get pushed out the bottom are the most vulnerable," says Rick Gentry, president and CEO of the San Diego Housing Commission, which operates within the city of San Diego and focuses its homelessness-fighting efforts on veterans, families and people who have behavioral health issues.

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"They tend to have mental health or substance abuse issues. They may have employability problems or a lack of extended family to fall back on when times are tough," Gentry says. "They don't have the resiliency to fend for themselves."

The chronically homeless and super-users of health care services like emergency rooms and ambulances are key populations the county and its partners are targeting through its Whole Person Wellness initiative, a pilot program funded by approximately $22 million in federal dollars that the county is slated to match during the next three years. Case management teams work to identify participants for the project and connect them with housing, health care and other services, as well as measure their progress and serve as points of contact for up to two years.

The service teams are comprised of a social worker and peer-support specialist – someone who has been homeless previously and may have had behavioral health issues – who are then supported by a nurse, a housing navigator and a mental health specialist.

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8,576 sleep homeless in san diego each night. 1300 of these are Veterans. These numbers are arguably very low as the point in count counters It is our mission to put a end to the epidemic of homelessness among our veterans. No veteran that has served our country should have to sleep

The San Diego Housing Commission (SDHC), a leading partner in addressing homelessness , is committed to increasing the number of housing opportunities that serve low-income and homeless individuals and families in the City of San Diego .

"How do we take a multisymptomatic person and better manage their care so, one, we improve their stability, but two, we're managing costs? Because we knew what the cost implications were from leaving them untreated," says Nick Macchione, director of the county's Health and Human Services Agency, which manages the initiative.

Similar programs have been approved in approximately 25 other California counties and are being administered through a Medicaid Section 1115 waiver, which allows states to test new health care approaches.

While different jurisdictions may be administering Whole Person Care slightly differently, the underlying theory of each program is that the coordination of health and social services will result in better patient outcomes and a more efficient use of public dollars.

Several counties are using data-sharing to coordinate services. In San Diego, members of the service integration teams will receive a text message when one of their patients is admitted to a hospital so they can immediately assess the situation and intervene.

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Whole Person Wellness also will have its own module within the county's data management platform, ConnectWellSD, so partners can easily share and access information about, for example, a patient's health care interactions or dust-ups with law enforcement.

That's additionally how the Health and Human Services Agency will track the program's outcomes and estimate expected cost savings.

"We all know whether it's the jails, (emergency department), other government safety nets, human services or health care providers, we all need that data, with obviously vigilant privacy in maintaining that," Macchione says. "Being able to really treat and help them with that Whole Person Wellness approach … is an amazing pilot that's allowing us to pull in the digital platform, that digital backbone, and also players that really haven't been in this space, like health plans."

The main way the county is identifying potential participants is through insurance claims data from major health plans in the area, which are sharing claims from as recently as 2017. After pinpointing patients enrolled in Medi-Cal – the state's Medicaid program – with medical costs of $20,000 or more in a single year, the county will cross-reference those names against data from their homeless management information system and internal behavioral health information.

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"We can see people who have had multiple psychiatric emergencies, or touches with law enforcement for mental health reasons," says Susan Bower, assistant director of integrated services with the county's Health and Human Services Agency. "So we're identifying that group and giving their names to the services integration teams so they can work … with their community contacts to find those individuals."

The goal is to serve 1,049 patients in all, recruiting through street outreach via "people who have experienced challenges themselves (who can) develop that trust and rapport with this population and really understand where they're coming from," Bower says.

The county also is beginning to take referrals for potential participants from hospitals and other community partners, who tend to know which patients could be a good fit for the program because they turn up so often. If those patients aren't enrolled in Medi-Cal – a requirement for the program because it's run through a Medicaid waiver – the county can help enroll them and bring them into the Whole Person Wellness group.

"We've got hospitals who are seeing people five, six, seven times, over and over in the emergency department," Bower says. "To tell the hospital, 'Oh, sorry, they're not on our list,' isn't going to work, so we've definitely opened it up so that we can accept community referrals."

And to ensure Whole Person Wellness is a long-term initiative, San Diego County plans to reinvest the money it saves back into the program.

The program is based partially on Project 25, a supportive housing pilot the county collaborated on with local homeless services provider Father Joe's Villages between 2011 and 2013, funded by a $1.5 million grant from United Way. The goal was to identify 25 chronically homeless people who were super-users of public services, and use a "housing first" model to help them get back on their feet.

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Such an approach puts homeless people in permanent housing first and then connects them with supportive services as necessary, rather than enrolling them in services while they're living in temporary shelters or making their housing contingent upon staying sober, attending health classes or fulfilling other requirements.

The model, increasingly favored by the U.S. Department of Housing and Urban Development in recent years, is based on the premise that getting someone out of a volatile living situation is key to helping them recover from an addiction, hold a steady job or otherwise begin to stabilize their life. If someone is living in a temporary shelter while battling substance abuse or other issues, it can be too difficult to focus on getting their life back on track, says Gentry, of the San Diego Housing Commission, which has been involved with the implementation of both Project 25 and Whole Person Wellness.

"Sometimes what the emergency and interim shelters tend to be are not always the best for that," Gentry says. "So housing first is, get them a place to live and then have them deal with whatever issues are contributing to their being homeless in the first place."

Project 25 ended up taking 36 people for the initial pilot, none of whom have wound up back on the streets since the program began. The average number of yearly hospitalizations plummeted from 10 to two, and nearly $2.1 million was saved in ambulance rides, jail days and other public services between 2010 and 2013, according to an analysis that included 28 of the original patients.

The sharp declines in costs and service utilization shows initiatives like Project 25 can be "hugely successful," says the Rev. Jim Vargas, a Roman Catholic deacon and president and CEO of Father Joe's Villages, which still operates the program today with about 50 to 60 participants.

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Charles West, 54, has been with Project 25 since January 2015, when he says he was discharged after 13 months in the hospital for health complications from alcoholism and drug use. It took some time, but he's now sober, taking classes at San Diego City College and living in an apartment provided by Father Joe's Villages.

A native of Memphis, Tennessee, who had been homeless for about five years, West credits the program with saving his life and encouraging him to regain some independence.

"I think all big cities should have something like this," West says. "At least to give some people that are very sick a chance to get back on top. And if they can't, at least they tried to help them. That's all anybody can do. You can lead a horse to water, but you can't make them drink."

A key difference between Project 25 and Whole Person Wellness is that Father Joe's Villages administers essentially all of the services it provides – housing, mental health and other individualized care– whereas the county is connecting patients with those services, maintaining relationships with participants and tracking their progress.

"In a broad context (Project 25) definitely shaped our thinking," Macchione says. "The key takeaway back then was we were treating all a person's needs, from getting them off the street and housed to getting them food, getting them medication, getting them stabilized. We called it a full-service partnership."

Vargas says he'd like to expand Project 25 further, but funding has been a major challenge. Despite the savings to hospitals and other public agencies, they have not been willing to fund it, he says. So while Father Joe's Villages gets some grant money for Project 25, it is largely privately funded.

"You'd think everybody in the community would look at this – the various entities, the health care system and so forth – and think, 'Wow, this is incredible and we should provide the funding so this continues,'" Vargas says. "But the reality is that hasn't happened. … We have continued with the program, but we truly don't have the funding we need to make as much of an impact as we know we can make."

That's a lesson Macchione and his team drew on when initiating Whole Person Wellness. Instead of petitioning the region's hospitals to consider funding the program once the three-year grant is up, Macchione wants health insurers to pay for it – if the county can demonstrate "true savings," he says.

In July 2019, the county also will work with Medi-Cal Managed Care to implement a Health Homes initiative, a care management mechanism created through the Affordable Care Act for Medicaid beneficiaries with complex chronic or mental health conditions – a target population similar to those the Whole Person Wellness initiative seeks to reach.

"Locally, we're starting to think with the health plans, 'How does Health Homes work as the sustainability (model) for Whole Person Wellness?'" Bower says. "It's just the idea of braiding funding across different sectors so that we can pull this whole thing together."

Copyright 2017 U.S. News & World Report

This Ohio neighborhood wants to pay homeless people to pick up trash .
A program to pay homeless people to pick up trash in an Ohio neighborhood could begin soon. The Columbus Dispatch reports that organizers are seeking $40,000 from the city of Columbus to launch a yearlong pilot program in the city's Franklinton neighborhood. The goal would be to pay homeless people $10 an hour to clean up homeless camps and surrounding areas. Organizers also hope to direct participants to resources that will help them find jobs, housing and medical treatment. One of the groups behind the effort, a charity called Jordan's Crossing, helped run a similar, but smaller program, in Franklin Township earlier this year. Franklin Township Trustee John Fleshman says workers cleaned up more than 5,000 pounds of garbage.

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