Donna Biederman Emily Carmody Mina Silberberg Increasing Housing Stability Assessing Promising Tenancy Support Models to Inform Local State and National Policy and Practice Increasing Housing Stability Assessing Promising Tenancy Support Models to Inform Local State and National Policy and ID: 766644
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Donna Biederman, Emily Carmody, Mina Silberberg Increasing Housing Stability: Assessing Promising Tenancy Support Models to Inform Local, State, and National Policy and Practice
Increasing Housing Stability: Assessing Promising Tenancy Support Models to Inform Local, State, and National Policy and Practice
Housing matters… Homelessness is a risk factor for poor health:1-4 Research shows that Permanent Supportive Housing is associated with less homelessness and improved health. 5-12 Medicaid funding can increase supply of PSH More research needed on TSS services Risk associated with poor implementation
Study goalStudy promising practices in tenancy support services (TSS) to provide information to North Carolina Department of Health and Human Services (NC DHHS) for Medicaid funding.
Key stakeholdersNC DHHS Louisiana Department of Health (LA DOH) and LA Housing Corporation Consumer Advisory Council (CAC) NC Agencies: Homeward Bound, UNC Center for Excellence in Community Mental Health
Our research questions What constitutes effectiveness of supportive housing? Is improved health one of those outcomes?What are the practices of effective TSS providers? Which aspects of provider agency context support effective TSS that is responsive to client needs and accessible to a diverse population? Which create challenges? Which aspects of local, state, and federal regulation support delivery of effective TSS that is responsive to client needs and accessible to a diverse population? Which create challenges? What are the benefits and challenges for providers to use Medicaid funding for TSS?
Methods
Our study design
Data sources Conducted interviews and focus groups with key sources in NC and LA (90 participants):Homeward Bound UNC Center for Excellence NC DHHS leaders LME/MCO housing specialists LA state leaders LA agency leaders Quantitative data (Clients with activity from 10/01/13 - 9/30/17):NC HMIS UNC Center for Excellence program data
Results: Who is PSH serving?
Relationship to head of household (n=7995)* Relationship to HOH Frequency % Self (HOH) 5380 67.3 HOH’s Child 2130 26.6HOH’s Spouse 296 3.7Other relationship to HOH 158 2.0 Other (non-related household member) 31 0.39 *466 missing
Characteristic Mean w/SD or n(%) Age in years (n=5115 ) 45.5 +/- 11.2 Race (n=5108) Black 2832 (55.4) White 2064 (40.4) American Indian / Alaska Native48 (0.94) Other164 (3.2) Gender (n=5115) Male 2888 (56.5) Female 2212 (43.3) Trans 15 (0.29) Veteran status (n=5106) Yes 955 (18.7) Key client characteristics for heads of household > 18
Disabilities (n=5115) Disability Frequency % Any type of disability 4895 95.7 Mental health384175.1 Substance abuse210241.1 Cognitive issues2104.1HIV/AIDS 3326.5Other physical health2204 43.1 Other 26 0.5
Number of episodes of homelessness in past 3 years (n=3408) # of times Frequency % 1 1791 52.6 2 391 11.53 242 7.1 4+ 984 28.9
Number of months experiencing homelessness in past three years (n=2988) # of months Frequency % 1 522 17.5 2-6 588 19.77-12 357 11.9 >12 1521 50.9
Program length of stay in days for first episode (n=2708) Mean SD Median Minimum Maximum 1000.9 964.1 705 07382
Housing at program discharge (n=2468) Housing type Frequency % Permanent housing – no subsidy 928 37.6 Housed with subsidy 859 34.8 Tenuous housing 190 7.7 Homelessness 180 7.3 Facility 138 5.6 Jail, prison, or juvenile detention 106 4.3 Other 67 2.7
Results: What are the outcomes of effective TSS?
Prevalent outcomes of PSH cited across respondentsIncreased housing and housing retentionImproved health Social connectionsOverall quality of life “It’s just something you would have to experience, to see the glow on their faces. …You see the light come on in their life, you know, by just having housing -- stable housing.”
Income and benefits at entry to and exit from services* Asset % at Entry % at Exit Income (n = 4870) Any type of income 43.5 76.4** Earned income 12.423.1** Disability income23.950.0**Non-cash benefits (n=4870) Any type of non-cash benefits50.172.1** Insurance (n=4870) Any type of insurance 58.1 71.4** Medicaid 41.8 53.2** *If not yet exited, % at latest recorded point. **Change from entry to exit is statistically significant using McNemar's Test and p<.05;.05/14 (.0036) = Bonferroni-corrected alpha level.
Finding stable housing might require instances of rehousing. It takes some people years to become invested in having a home.Some people require on-site supportive housing like RHD and Woodfin. Being housed can mean the loss of former social connections. Some people become sicker when housed, e.g., by not eating well. The health-housing relationship can be bi-directional. Can be difficult to balance different housing needs. ...realizing its full potential can require ongoing services. TSS can have enormous benefits, and….
What are promising practices for service delivery?
Agencies identified shared promising practices for providing effective tenancy support services. Housing FirstStaff trainingIndividualized, flexible servicesCreative problem-solving within formal protocolsSpecialized positions and teams
The biggest challenge for TSS providers is locating affordable, safe, decent, and accessible housing
TSS increases landlord and developer willingness to provide access to units. Effective TSS Access to Housing
What are key factors to consider in the policy/regulatory environment?
Louisiana has seen benefits from using Medicaid funding for TSS… Increase in independenceReduced hospitalizationsReduced institutional careImproved health outcomes Reduced Medicaid expenditures …. and NC respondents are excited about this too.
Creating an effective service definition requires balance.
STATE INFRASTRUCTURE Braided Funding Collaboration Across Agencies QA at all Levels Training and TA at all Levels Balance requires infrastructure to support implementation. EFFECTIVE TSS
Impact
Research symposium held in April. Collaborative learning Relationship building Policy impact New project ideas
Implementation of CST for tenancy supports changed. LME/MCO technical assistanceQuality review checklist to evaluate providers Intensive provider training New quality assurance process Request for evaluation
Informed Healthy Opportunities service definitions and rate settings. Participated on North Carolina Healthy Opportunities Fee Schedule Advisory Panel Research assisted in identifying services and payment strategy
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