Health Care Reform & Homelessness research study March 3, 2016

Photo: Point-in-Time Study

Health Care and Homelessness Crista Gardner, Chair Leo Rhodes, Vice-Chair Jeannemarie Halleck, Lead Writer Health Care and Homelessness research committee For more information, please go to: www.pdxcityclub.org/healthcarehomelessness

City Club of Portland 

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nonprofit, nonpartisan education and research based civic organization dedicated to community service, public affairs and leadership development weekly Friday Forums community-based research and advocacy after-hours civic programs

Interviews & literature review Interviews completed  Kristina Smock  Bob DiPrete  Dr. Rachel Solotaroff  Ed Blackburn  Metro Councilor Sam Chase  Gary Cobb  Ibrahim Mubarak  Rachael Duke  John Duke  Carolyn Bateson  Christy Ward, David Hidalgo, & Mary Li  Janet Meyer & Dr. David Labby City Club events  Nan Roman  Friday Forum Homelessness Panel

Readings & written summaries completed 

Over 50 articles & reports

Healthcare reform

Homelessness

Multnomah County

City Club research study How can the maximum health benefit for the homeless population of Multnomah County be achieved from health care reform and expansion of the Oregon Health Plan?

Key conclusions 1.

2.

3.

Heath coverage is now a reality for many people experiencing homelessness It’s difficult to become healthy when you are living on the streets The full potential of the Medicaid expansion is undermined by lack of housing

Homelessness in Multnomah County

Photo: John Rudoff

2015 Point-in-Time Count

2015 Point-in-Time Count

Why homeless? 2013 Point in Time Count 

“Homelessness is first and foremost an economic issue”  High

rents  Low pay  No pay  Low vacancy  Chronic disabling health conditions  Crisis (e.g. medical care, job loss) 

Domestic violence

Homeless populations 2013 Point in Time Count 

Two distinct populations:  chronically

homeless individual adults with disabling

conditions  short-term and recently homeless and includes growing numbers of families with children, many of whom are people of color and/or victims of domestic violence

Characteristics of homeless 2013 Point in Time Count 80% 71% 70% 60% 52%

53%

50% 41% 40% 28%

28%

30%

19%

20%

11% 10% 0%

Chronically homeless

Disabling conditions

Individuals Families with Affected by Females children domestic affected by violence domestic violence

Veterans

Multnomah County for less than a year

Characteristics of homeless 2013 Point in Time Count 90% 81% 80% 70%

69%

60% 50% 40% 30% 20%

20%

13% 8%

10%

7%

11%

2%

9% 2%

3%

1%

0%

White

Asian

Black or African Hispanic/ Latino Native American Native American or Alaska Native Hawaiian/ Pacific Islander 2013 HUD

Multnomah County

Characteristics of homeless 2008 Vulnerability Index Study 100% 90%

88%

80%

80% 70% 60%

45%

50% 40%

30%

30%

21%

20%

28%

10% 0%

No income Income is Have been to Have been to Victim of Have been in except food panhandling* jail prison violent attack foster care stamps* while homeless * Of the most vulnerable

1. Heath coverage is now a reality for many people experiencing homelessness

Photo: Pedro Oliveira's "Careful: Soul Inside"

Oregon Health Plan (Medicaid) Expansion  

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All homeless qualify 138% of federal poverty level 1,050,178 of 4 million Oregon residents enrolled 26.1% of Multnomah County residents qualify Holistic care

Oregon Health Plan (Medicaid) Enrollment in Oregon 

Successful State of Oregon enrollment  SNAP  Police  Clinics  Hospital



emergency departments

Challenges to enrollment  email

address, phone number or permanent address  some states have not signed onto the Medicaid expansion

Oregon Health Plan (Medicaid) Benefits to homeless     

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

Consistent treatment Preventative care Specialist care Less emergency department visits Prevent homelessness due to medical debt or untreated illness Free up money for nonprofit groups to spend on housing Leverage resources

Coordinated Care Organizations Overview  

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$1.9 Billion from federal government Reduce per capita growth of Medicaid spending (from 5.4% to 3.4%) Show progress on 33 measures Flexibility in allocation of Medicaid services Coordinate care among providers

Coordinated Care Organizations Overview of 2015 Performance Report Between 2011 to 2015:  

Emergency department visits decreased 23% Hospitalization for chronic conditions decreased:  chronic

obstructive pulmonary disease by 68%

 short-term

complications from diabetes by 32%

2015 Performance Report Emergency Department Utilization 

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Rate of patient visits to an emergency department in 2011, 2014 & 2015 Benchmark: 39.4

2015 Performance Report Outpatient Utilization 

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Rate of patient visits to a doctor's office or urgent care in 2011, 2014 & 2015 Benchmark: 467.3

2015 Performance Report Patient-centered Primary Care Home Enrollment 

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Percentage of patients who were enrolled in a recognized patient-centered primary care home in 2012, 2014 & 2015 Benchmark: 100%

2. It’s difficult to become healthy when you are living on the streets

Photo: Oregonian

Health outcomes Homelessness and health 

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Lifespan of a person experiencing homelessness is 30 years less than that of a person who is housed. Homeless people are three to six times more likely to become sick than housed people. Health outcomes include: traumatic brain injury  seizures, arthritis, COPD, musculoskeletal disorders;  skin and foot problems;  increased risk for TB, HIV;  inadequately controlled chronic conditions;  environmental exposures: frostbite, heatstroke; and unintentional injuries and trauma 

Health outcomes 2013 Point-in-Time Health outcomes of unsheltered homeless population 27% 16%

1%

5%

17%

17%

18%

20%

Health outcomes of homeless 2008 Vulnerability Index 40%

36%

Vulnerability Index Other indicator

35% 30% 25%

21%

20% 15% 10% 5% 0%

3%

3%

4%

6%

7%

9%

11% 12%

14%

24% 24%

Health outcomes & mortality Multnomah County Mortality Study 

56 deaths in 2012:  accidental

and trauma  most related to drugs and alcohol

2012 accidental

natural

suicide

homicide

4%

 intoxication

18%

 natural  suicide  homicide

53% 25%

Health outcomes & pain management National Healthcare for the Homeless Conference 

Barriers to pain management:        

the stress of shelter life, poor sleeping accommodations, inability to afford medications, transportation problems, adverse reactions to medications, belief that medication ineffective, problems with doctor/patient relationship and inability to restrict physical activity.

60%

50%

48%

46%

43%

40%

30%

20%

10%

0%

29%

Health services for homeless Safety Net Providers 

Safety Net Providers, like:  Central

City Concern: Old Town Clinic  Outside In  NARA Indian Health Clinic  The Wallace Medical Concern   

Multnomah County clinics Portland VA medical center Emergency departments

Health service utilization 2008 Vulnerability Index Vulnerability Index Study 43%

 

34% 

Over 3X Hospital Over 3 ER Visits in or ER admits in last last 3 months year

63% uninsured Estimated cost of $492/visit Estimated cost of $1.43 million per year for the 730 visits of study participants

3. The full potential of the Medicaid expansion is undermined by lack of housing Photo: Street roots

Health service utilization Bud Clark Commons In first year:  45% decline in average total health care costs for residents on Medicaid  one-half of a million dollars total cost Medicaid reductions

Total Costs per member per month residents of Bud Clark Commons with Medicaid $1,626

$899

$995

$680 $454

Year Before Move-In

1st Year After

2nd Year After

Beyond 2nd Typical Adult Year Medicaid Member

Health service utilization Bud Clark Commons $250

Total costs per member month before and after moving into Bud Clark Commons with Medicaid

$213 $200

$150

$100

$70

$87 $61

$58 $32

$50

$25 $29

$21 $24

Beyond 2nd Year

Typical Adult Medicaid Member

$-

Year Before Move-In

1st Year After 2nd Year After

Emergency Department

Outpatient Primary Care

Health service utilization Bud Clark Commons After moving into BCC:  $8,724 reduction of in annual claims for the average resident  Costs $11,600 annually to house a resident at BCC  The reduction in claims was maintained  Supportive housing had a profound and ongoing impact on health care costs for those living at BCC

Bud Clark Commons Residents with Medicaid Year Before Move-In 1st Year After 2nd Year After 6.9 5.8 5

2.8

2.5

1.9 0.630.75

1.3

Average # of Average # of Average # of hospitalizations ED visits outpatient visits

Key conclusions 1.

2.

3.

Heath coverage is now a reality for many people experiencing homelessness It’s difficult to become healthy when you are living on the streets The full potential of the Medicaid expansion is undermined by lack of housing

Thank you!

Thank you! Crista Gardner, Chair Leo Rhodes, Vice-Chair Jeannemarie Halleck, Lead Writer Health Care and Homelessness research committee For more information, please go to: www.pdxcityclub.org/healthcarehomelessness