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TRANSCRIPT
Summer SeriesAddressing the Homeless Crisis In San Diego
Dare You To Move
August 26, 2019
August 26th Event brought to you by
Argos Health VA Webinar• Confidential
COMPLEX CLAIMS: DO ONE THING & DO IT WELL
Meet Argos Health
Our business is billing & resolving complex claims, and we pride
ourselves on managing challenging accounts to achieve maximum
reimbursement for our healthcare providers.
Thank you to our Chapter Sponsors
Time Session Speakers/Panelists
3:30 PM Registration
4:10 PM Welcome and Opening Remarks Mindy Scher , President 2019-2020, HFMA San Diego
4:10 PMPresentation on Homeless Task Force Brian Elliott, Policy Advisor for Councilman Chris Ward
Kris Kuntz, Homeless Taskforce
5:00 PMHASDIC & 2-1-1 Present: Partnerships in Transition Planning for Homeless
Caryn Sumek VP, HASDICCamey Christenson SVP, 211 San Diego/Imperial
5:30 PMScripps Health Presents Best Practice for compliance with SB1152
Violeta Aguirre, Manager Public Resource Specialists, Gladis Moore Case Management
Agenda
Kris Kuntz and Brian Elliott
Regional Task Force on the Homeless
Before we get started…Our beliefs
• “Homelessness is unacceptable.” President Obama
• Homelessness is a situation… it does not define someone. It is not a label.
• Homelessness is not a choice, but rather the result of larger structural issues and failed public policy.
• Homelessness is solvable. We have seen countless communities end Veteran homelessness. If it can be done for one population it can be done for all.
Extent of the Problem Nationally
552,830 total persons experiencing homelessness on any given night in 2018.
129,972 (24%) are in California
Homeless History 101• Although homelessness has been around for a long time (NYC Bowery – Soup, Soap, and Salvation)
it did not exist like it does today.
• While people sometimes experienced evictions or involuntary moves because of personal or financial crises, homelessness was predominantly experienced by single adults
• Prior to the 1980s, in most American communities there was a sufficient supply of affordable rental housing to low income families
• The increase in homelessness since the 1980s was the result of several key factors: 1. The loss of affordable housing and increase in foreclosures
2. Wages and public assistance have not kept pace with rising housing costs and the cost of living
3. Closing of state psychiatric institutions without the creation of sufficient community-based housing and services.
4. The rapid increase in income inequality that began during the 1980s has contributed to changes in local housing markets, driving up the cost of renting even a modest home or apartment.*
*Housing affordability problems and homelessness tend to be greatest in communities with higher levels of income inequality.
Source: USICH Opening Doors: Federal Strategic Plan to Prevent and End Homelessness
Why America Can’t Solve Homelessness
“As the economy has come out the Great Recession, America’s unhoused population has exploded almost exclusively in its richest and fastest growing cities…”
“In other words, homelessness is no longer a symbol of decline. It is a product of prosperity… the vast majority of people being pushed out onto the streets by America’s growing urban economies do not need dedicated social workers or intensive medication regimes. They simply need higher incomes and lower housing costs.”
A few numbers…
$931Monthly payment for someone who is
elderly, blind, or disabled in CA (SSI)
$34.69Hourly wage required to afford a two bedroom
apartment in California in 2018 (National Low Income Housing Coalition)
28%Of San Diegans spend more than
50% of their income on rent
$1,950Total number of evictions per day in San
Diego County (2016)
10Median rent for 1 bedroom in San Diego
9,000Nearly the total number of people who became homeless for the first time in
San Diego County (2017)
Trends in Homeless Population
About 1 in 5 considered chronically homeless –lengthy homeless history and disabling condition
Trends in Homeless Population: Race
Source: SPARC Phase One Study Findings (March 2018) Center for Social Innovations
Extreme Racial Disparities Exist
San Diego County: 5% Black/African American in General Population compared to 23% in unsheltered population
Trends in Homeless Population: Aging
Source: https://www.aisp.upenn.edu/wp-content/uploads/2019/01/Emerging-Crisis-of-Aged-Homelessness-1.pdf
Trends in Homeless Population: Aging and Costs
Los Angeles: Average Annual Cost by AgeNew York: Average Annual Cost by Age
34% of San Diego homeless population is age 55+
Trends in Homeless Population: Costs
LA County found that they spend nearly $1 billion annually on homeless single adults.
(Note: This is just what the local county government spends and only on singles not families)
Santa Clara County found that they spend $520 million per year on homelessness
What’s happening in San Diego?
2019 Point In Time Count
Point In Time Count Trends
Regional Task Force on the Homeless
• Through the Homeless Emergency and Rapid Transition to Housing (HEARTH) Act, HUD requires Continuums of Care (CoC) to do the following:
• Designate a Homeless Management Information System (HMIS)
• Implement a Coordinated Entry System
• Develop Written Standards for service provision
• Measure performance – System and program level
• Prepare annual application for funding
• Conduct Point-In-Time Count
• Regional Leader on addressing homelessness, convene key stakeholders, system developer, and support policy creation that uses best-practices
Housing is a key social determinant of health
Opportunities for Partnerships
Self Reported Health Conditions of Unsheltered Population 2018
Cost of Homelessness in San DiegoProject 25: 28 people cost
$3.5 million in 1 year
Average Cost Per Person $125,000
Registry Week: 114 people cost $1.23 million in 1 year
Average Cost Per Person $11,000
In 2018 there were 2,171 chronically homeless individuals on any given night that range in costs from 11K to over 100K annually (low end spending $23 million per year)
Fortunately…Permanent Supportive Housing Works to Decrease Health and Other Costs
Project 25 Registry Week
Unfortunately…San Diego is significantly
lacking permanent supportive housing units compared to
other urban metros
Opportunity: Could healthcare be a partner with government, non-profits,
and private sector to create more units?
Flexible Housing PoolEnable homeless system to better access/use existing rental market allowing for the more efficient use of dedicated federal, state, and local rental assistance dollars and be a source for new/additional assistance.
Public Sector $(Cities and
County)
Private -Philanthropic
$
Health Sector $(Health Plans and Hospitals)
Pooled funding to be used flexibly to
“Do Whatever It Takes” to house
people
Fund Management
Entity and Landlord
Relationship Broker
Landlord Incentives –deposits, damage funds, incentive
payments
Voucher or subsidy gap payment
Long-Term Master Leasing
Shared Housing strategies/incentives
Direct rental assistance for
prevention, diversion, PSH and RRH
Unit holding fees or short-term master
leasing
Committed network of Non-Profit Homeless Services
Providers that would partner
with Fund Entity to
provider direct services
What could it look like in San Diego?
Other Opportunities
• Improved hospital discharge process – SB 1152
• Medical Respite/Recuperative Care
• Health Homes and other ways for Medicaid to pay for housing related services
• Technology/Data Integration for improved care coordination – (2-1-1 San Diego Community Information Exchange)
• Using healthcare data to prioritize persons for Permanent Supportive Housing
• Addressing encampments with Street Medicine – Medication Assisted Treatment
Contact Info
Kris Kuntz
Brian Elliott
Thank you to our Chapter Sponsors
SB 1152California’s Hospital Discharge
Policy for Homeless Patients
Caryn Sumek, Vice President
Purpose of Policy
To help prepare the homeless patient for return
to the community by connecting the individual
with available resources, treatment, shelter, and
other supportive services.
Overview
What is Senate Bill 1152?
The law requires general acute hospitals, acute psychiatric hospitals, and
special hospitals to:
Establish a written process to make sure adequate post-hospital care
arrangements are made for homeless patients
Coordinate services and referrals with community partners (behavioral
health, medical care, and social services agencies)
Maintain a log of the homeless patients discharged from facilities and
the post-discharge destinations of each homeless patient
Maintain a resource list of local homeless shelters, including their
operation hours and admission procedures
Effective January 1, 2019
Implement a Written Discharge Planning Policy & Procedure“Each hospital, as defined in subdivisions (a), (b), and (f) of Section 1250, shall include within its hospital discharge policy a written homeless patient discharge planning policy and process”
Identify housing status
Provide information in a culturally competent manner
Provide an individual discharge plan to homeless patients
*Identify a post-discharge destination
Required Elements:
* Will be discussed in detail next slide
*Identify a Post-Discharge Destination
• Social services agency, nonprofit social services provider, etc.a) Receiving facility must have agreed to accept the homeless patient AND the patient
must agree to the placementb) The hospital must document the name of the person at the receiving facility who
agreedc) Hospital must send written or electronic information about the homeless patient’s
known post-hospital health and behavioral health care needs to receiving facility
• Homeless patient’s “residence” (his/her principle dwelling place)a) Examples: friend’s house, tent, park or other area
• An alternative destination, indicated by the homeless patient
Effective January 1, 2019
Hospitals Must Offer to Provide Homeless Patients Services
“There is no requirement that the patient accept any of the services that the hospital offers. A patient may refuse any or all of the services offered. The hospital should document the offer and the refusal”
Physical examination and determination of stability for discharge Referral for follow-up care Transporation Offer a meal Offer weather-appropriate clothing Medications (if needed) Health coverage enrollment assistance Infectious disease screening Vaccinations
Required Services
Effective July 1, 2019
Implement a Written Plan to Coordinate Services and Referrals with Community Partners
Required Elements:
A list of local homeless shelters (must include other information – found in manual)
Hospital’s procedures for discharge referrals
Training protocols for discharge planning staff
Effective July 1, 2019
Maintain a Homeless Patient Log
Required Elements:
All homeless patients who are discharged
Indicate if they were admitted as an inpatient or seen as an ER outpatient
Evidence of completion of the homeless discharge protocol in the log OR in patient’s medical record
Please don’t hesitate to contact us with any questions!
Caryn SumekVice PresidentP: [email protected]
THANK YOU!
• 2-1-1Overview
• Community Information Exchange Overview
• CIE Impact & Outcomes
• Leveraging CIE for SB1152
Brief Agency Overview
Food
Benefits and
Enrollment
Veterans
Courage to Call
Health
Health
Navigation
Housing
Housing
Navigation
2-1-1 Overview
2-1-1 San Diego
• Information and Referral Services
• Navigation Services
• Resource Database: 1,300 agencies and over 6,000 services
2-1-1’s values• Deliver WOW through Service• Embrace and Drive Change – Evolve• Create Fun and A Little Weirdness• Be Adventurous, Creative, and
Open-Minded• Pursue Growth and Learning• Build Open and Honest Relationships
with Communication• Build a Positive Team and Family Spirit• Do More With Less• Be Passionate and Determined• Be Humble
2-1-1’s purpose is to make positive, lasting
impacts on people’s lives and drive meaningful
change throughout our communities.
2-1-1’s mission Our mission is to serve as a
nexus to bring the community organizations
together to help people efficiently get
appropriate services, and provide vital data and
trend information for proactive community
planning.
TODAY500,000
connections/year
1,200+service providers
200+languages offered
92%customer satisfaction
150+highly trained staff
Food
Benefits and
Enrollment
Veterans
Courage to Call
Health
Navigation
Housing
Navigation
What we
knowSocial influences greatly impact health
2016 San Diego Collaborative Community Health Needs Assessment
AssessmentTOP HEALTH NEEDS TOP SOCIAL NEEDS
Bridging gaps between social and health services
Navigation for Social Needs:
CIE Brief Overview
Person CenteredModel Model
Income & Benefit
Programs
Housing Services
Food Services
Healthcare Services
Local food banks & meal
programs
(SD-OASIS)
Homeless Management
Information System HMIS
(Clarity/CSTAR)
Ambulance transport,
Healthcare systems, Hospitals,
Community Clinics, Health Plans
(Individual EHRs, SD-WATER-EMS
transports, HIE, )
CalFresh, Medi-Cal,
CalWorks, General Relief
(C4, CalWin, ConnectWell)
Data Systems
Community Information Exchange (CIE):
An ecosystem comprised of multidisciplinary
network partners that use a shared language,
resource database, and integrated technology
platform to deliver enhanced community
planning.
Technology Platform and Data Integration
Technology software that integrates with other platforms to populate an individual record and shapes the care
plan. Partners access the system. System features include care team communication feeds, status change alerts, data source auto-history and predictive analytics.
Shared Language (SDoH)
Setting a Framework of shared measures and outcomes through 14 Social
Determinants of Health Assessments and a Risk Rating Scale: Crisis, Critical, Vulnerable,
Stable, Safe Thriving
Bidirectional Closed Loop Referrals
Updated resource database of community, health, and social service providers. Ability
to accept/return referrals and to provide outcomes and program enrollment.
Community Care Planning
Longitudinal record with a unified community care plan that promotes
cross-sector collaboration and a holistic approach.
Community Information Exchange
Core Components
Network Partners
Collective approach with standard Participation Agreement, Business Associates Agreement and
participant consent with shared partner governance, ongoing engagement, and support.
Community Information Exchange Partners
Healthcare Sector
Health Plans
Hospitals
Emergency Medical Services
Health Information Exchange
Behavioral Health
Public Health
Network Partners
Health Centers
Social Services Sector
Housing
Multi-Service
Human Development and Aging
Legal
Employment
Nutrition
Network Partners
GovernmentNetwork Partners
Primary
Care and
Prevention
Housing Stability Health
Management
Nutrition & Food
Security
Legal &
Criminal
Justice
Safety &
Disaster
Transportation Employment
Development
Personal Care &
Household
Goods
Financial
Wellness and
Benefits
Education &
Human
Development
Social &
Community
Connection
Activities of
Daily Living
Utility &
Technology
14 Domains: Risk Rating Scale
CRISIS CRITICAL VULNERABLE STABLE SAFE THRIVING
KNOWLEDGE AND UTILIZATION
BARRIERS AND SUPPORTS
IMMEDIACY
Risk Rating Scale ToolRisk Rating Scale Tool
• Each assessment is built to as an algorithm to
plot clients on a crisis to thriving scale
• Shared across all agencies and can be
updated by agency data through integration
• Shows a history of client change and by which
agency to move up on the continuum
• Examine client need by domain accounting for
the follow factors:
1. The nature, severity, & immediacy of the
need
2. The barriers and supports available to
client in meeting that need
3. The client’s knowledge and capacity to
utilize resources to meet that need
Housing Assessment Snapshot
61
• Shared taxonomy language for referrals
(AIRS)
• Dedicated resource staff
• Regular updates made to resources
• Standards to listings and requirements
• Inclusion/Exclusion Criteria
• Linked to health conditions
• Tracks resource availability and unmet
needs
Resource Database
Client Record SampleClient Profile
• Demographic and important information about the client
Domains• Examples like Housing, Food & Nutrition, • Categorization of Needs (SDOH) & Risk Level• Shared Assessments and Values across agencies
Care Team• Case Managers working with client across agencies• Contact Information
Referrals & Program Enrollment• Agencies or programs client is referred• Connection to Services
Alerts• Notification of emergency services & jail• Ability to notify Care Team Members of changes
Feed• Ability to communicate with Care Team members
(twitter-like feed)
63
Alignment with San Diego Initiatives
Health Homes (health plans and FQHCs)
Homeless Prevention Collaborative (HEAP)
Whole Person Wellness
Connect Well Integration
Social Determinants of Health/Eligibility
Impact & Outcomes
66
Benefits of CIE
Macro (Community)
Data that Speaks
Unmet Needs and Barriers
Access Disparities
Mezzo (Agency)
Bridges sectors
System Efficiencies
Shared language and outcomes
Micro (Family & Individual)
Informed and Tailored Services
Proactive Engagement
67
Impact of CIE
Reduction on
healthcare
utilizationImprovement in
social and health
wellness
Better Health
Outcomes
Evidence for Success
Improved
Efficiencies in
connection and relationship to
resources
26%reduction
EMS Transports Post CIE
enrollment
Cohort 1: Homeless Cohort Analysis
44%
Cohort 2: Senior Cohort Analysis
Remained in stable
housingimprovement
CIE: ROI
ROI and Alignment
Patient Needs
(n =71)
CY 2016-2017:
• 92% decreased vulnerability
• 92% felt confident in the ability to
manage their health
22%
18%
4%
10%
7%
8%
4%
4%
2%
7%
7%
4%
1%
2%
0% 5% 10% 15% 20% 25%
Housing
Food and Nutrition
Utility and Technology
Transportation
Social Community Connection
Financial Wellness
Health Condition Management
Primary Care
Personal Hygiene HH Goods
Human Dev & Education
Employment
Legal
Disaster and Safety
Activities of Daily Living
9.6%
30.0%
211 Patients Comparison Group
Hospital Readmission Rates
Year 1: SDOH Outcomes
Anticipated ROI:• CTI program dramatically reduces preventable hospital readmissions for high-risk, vulnerable
patients
• Avoidable inpatient admissions ~ $17,564 per admission, and ER readmissions ~ $1,3871 ; higher
costs estimated for unfunded population
1Source: American Journal of Managed Care, 2011
Return on Investment
SB1152 Overview
SB1152 Requirements:
• Housing Status: Hospitals must document asking patients about housing status
• Post Discharge Destination: Hospitals’ Individual Discharge Policy requires hospitals to identify a post-discharge destination:
• Referral Acceptance: Hospital must document that social service agency has agreed to accept homeless patient; hospitals are encouraged to obtain written documentation FROM receiving entity
• Sharing Patient Information: The hospital must send written or electronic information about the homeless patient’s post-hospital health and behavioral health needs to receiving provider.
• Inform Patient: The hospital is required to inform homeless patient of available placement options and prioritize identifying a sheltered destination with supportive services.
• Other Social/Health Needs: Ensure access to Food, Clothing, Medication, Infectious Disease Screening, Vaccinations, Transportation, Health Coverage
74
Hospital Patient Discharge Process: homeless patients
75Product AreasLeveraging CIE
• 2-1-1 Resource Listings
• CIE Client Record
• Longitudinal client record with patient history, access to programs, HMIS
information, care team
• CIE Referrals
• Documentation of referrals (if not housing-referrals to day centers or outreach
workers)
• Documentation and Reporting
• Uniform documentation and tracking (unmet needs)
• Shared Reports and data
76Product AreasLeveraging CIE – Engagement Strategies
CIE Value:
• Create/initiate referrals to cross-sector partners
• Ability to view history from any data sources about the client
• Flag need for homeless/housing providers
• Receive alerts for future (Care Team)
• Holistic understanding of client/patient situation
• Co-occurring social determinant of health needs
• Risk Score, based on information available
• History of Assessments, calls, needs
SCRIPPS HEALTHHOMELESS
Identification in ED
Identification of coverage
Public Resource Specialists
HOS partnership with county
Patient Financial Services
Homeless
Patient
CareRevenue
Patient
Experience
Cost
to Care
SB 1152
Patient Access Component Clinical Component
• Identify the patients’ address
• Complete registration document
• Update the patients’ housing
status
• Add a patient FYI flag
• Identify any coverage
• Assist the patient with HPE
application if needed
Assess a patient’s homeless status at
each encounter
• Complete discharge planning including clothing, transportation, meal etc.
• After Visit Summary printing is restricted until Homeless documentation is complete
• Coordinating additional services for the patient if patient allows & understanding limitations for housing/shelter options for SD County
Homeless Patients System Wide
0
1000
2000
3000
4000
5000
6000
Mercy CV Mercy SD La Jolla Green Encinitas
# o
f Pa
tien
ts
Hospitals Sites
Patients
Total Visits
EPIC
Homeless
Patient
Discharge
Planning
Flowsheet
Community Resources and Partnerships
• Homeless patients receive a standard community resources based on their region, that provides information about local shelters, homeless service providers, and other resources.
• For those patients who are unable to return to their previous living situation, or are interested in establishing housing, we assist with exploring discharge options
Community Resources• Shelters – San Diego Rescue
Mission, St Vincent de Paul, PATH, Veterans Village of San Diego
• Independent Living Facilities• Board and Care Facilities• Single Room Occupancy Hotels
Scripps Partnerships• Catholic Charities, Motel Voucher
Program• City of Refuge, Recuperative Care
Shelter• Community Information
Exchange (CIE)
In-House Patients &
ED Patients
Applications
Responsible for the submission and monitoring of all
applications
Screening
Interview each patient to
establish which programs are
best for the patient
Liaison
Acts as the official liaison
between the Hospital
County HHSA HOS & FRC
programs
Technical
Resource
Assist case management and social work when patient funding impacts discharge planning and level of care
transfers
Additional Support
Including home calls, initiate applications with
DMV, VA, SDI and/or Social Security
Public Resource Specialists
HOPE Pilot(Hospital Outstation Point of Entry)
Collaboration Communication Vision
PFS
Financial
Assistance
• For patients who may
not qualify for Medi-Cal
coverage or who have a
remaining out of pocket
liability without the
ability to pay.
Bad Debt
• Last resort for patients’ who
are unresponsive to
collection attempts, not
identified as Homeless
Charity
• For patients’ who have not
established an ability to
pay and are considered
below the Federal Poverty
Level for full charity
adjustment or within
policy thresholds of the
Federal Poverty level for a
partial charity adjustment.
Assessment EducationContinuous
Enhancement
Questions?
Violeta AguirreManager Public Resource [email protected]
Gladys MooreManager Patient Access [email protected]
HFMA San Diego Imperial: Fall Conference
When: September 20th
Where: Courtyard by Marriott, San Diego, CA Join HFMA for a day of learning & networking featuring a keynote address by Dr. Jerry Teplitz providing an
introspective on Self-Development and a comprehensive healthcare federal policy update delivered by
Chad Mulvaney, HFMA Director, Healthcare Finance Policy, Strategy and Development
Upcoming Events
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January 12-15
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