Overview

In 2012, LA County Department of Health Services addressed homelessness and associated poor health outcomes via a multi-pronged, comprehensive housing program called Housing for Health (HFH) that included collaborative partnerships with community organizations, innovative funding streams, and transparent communication between all stakeholders.

Organization Name

Los Angeles County Department of Health Services

Organization Type

• Public Health System

National/Policy Context

• The U.S. disproportionately spends a greater percentage of its GDP on healthcare than social services (17% versus 9%) compared to other high income countries (15-21%), and boasts worse health outcomes, with lower life expectancies and increased prevalence of chronic disease. 
• Simultaneously, a paradigm shift in general public opinion encourages policymakers to more heavily prioritize value in health and healthcare.
  •  Yet health system leaders struggle to determine how to best invest savings to meet these new demands.
• Finally, research shows that when individuals with mental health and/or substance use issues are provided housing prior to beginning treatment, they are less likely to use expensive inpatient or ER services. 
• Per the US Department of Housing and Urban Development (HUD), homelessness criteria includes having “a primary nighttime residence that is a public or
• private place not meant for human habitation” or “living in a publicly or privately operated shelter designated to provide temporary living arrangements.” Those who experience homelessness can have:
  • Higher healthcare utilization: Homeless people have a higher proportion of chronic medical conditions (e.g., HIV/AIDS, schizophrenia, substance use) as compared to housed people and have prolonged gaps in care that lead to emergency department utilization (Salhi et al., 2018). 
  • Increased jail and prison interaction: More than 23% of homeless individuals come into contact with jail and prison systems and are 10 times more likely than housed people to be homeless after prison release. Over 80% of those released suffer from a chronic medical, psychiatric, or substance use problem. A year after release, only 15-25% of formerly incarcerated people report seeing a medical provider outside of the emergency department.  

Local/Organizational Context

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Patient Population Served and Payor Information

• The LA Public Health Department sees 600,000 unique patients annually.
  • This intervention had 2737 participants. 
• Payors include capitated Medicaid managed care, Medicaid fee-for-service, cost-based reimbursement. Medicare and private payers account for few payments; and 10% of patients are uninsured.
• From 2014-2017, LA’s homeless population increased by 45%. In the same time period, the county had the largest number nationally of jailed persons and prisoners at 18,000. Nearly 20% of those individuals were homeless previously. (Table 1).

Leadership

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Funding

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Research + Planning

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Tools or Products Developed

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Training

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Tech Involved

• Tracking software
• Web-Based Portal

Team Members Involved

• Administrator
• Case Management
• Data Analyst
• Mental Health Provider
• NPs
• Physicians
• Specialists
• Support Staff

Workflow Steps

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Budget Details

• Salaries and benefits for county workforce employees
• Services and supplies for County (includes contracts with service providers)

Where We Are

• Since its launch, HFH’s vast network enables it to meet the diverse needs of its clients. Its programmatic expanse boasts a breadth and depth that appropriately support clients wherever they may be, from those who require substance abuse support, for instance, to those who need more comprehensive mental health treatment, to individuals with temporary housing and job losses
• Referrals: In 2012 at the program’s launch, internal DHS hospitals and clinics referred individuals to HFH but over time, expanded partnerships with departments of health, mental health, public health, probation, diversion and re-entry, vocation and women’s initiative services provided increased referrals. Now, private hospitals, jail or custody centers, coordinated entry systems, street-based engagement teams, and mental health providers can also refer individuals to HFH.

Outcomes

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Future Outcomes

• Currently, HFH is working with partners and legislators to expand upon the services offered and make them eligible for Medicaid reimbursement. By mainstreaming their offerings, they can attain a new funding source and be less dependent on funding streams from philanthropic donors or those with a deadline/expiration date (i.e., sales tax revenues).

Benefits

• This program strove to provide housing and better health outcomes for a vulnerable population, and to improve overall quality of life. Much of its success owes to the gratification felt by employees who are able to provide comprehensive support to their clients. 
• Ultimately the program did lead to a decline in the homelessness population (at least in 2018), reduced law enforcement contacts, and decreased interactions with the healthcare system.

Unique Challenges

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Sources

• Gupta, R., Ghaly, M., Todoroff, C., & Wali, S. (2020, January). Creating value for communities: Los Angeles County’s investment in Housing for Health. In Healthcare (p. 100387). Elsevier.
• Salhi, B. A., White, M. H., Pitts, S. R., & Wright, D. W. (2018). Homelessness and emergency medicine: a review of the literature. Academic Emergency Medicine, 25(5), 577-593.
• Todoroff, Cheri. Personal communication. May 26, 2020. 
• U.S. Department of Housing and Urban Development. (n.d.) Homeless Definition. Retrieved from https://files.hudexchange.info/resources/documents/HomelessDefinition_RecordkeepingRequirementsandCriteria.pdf