HOUSING AS HEALTHCAREJoshua D. Bamberger, MD, MPH

Josh.bamberger@sfdph.org

San Francisco Department of Public HealthUniversity of California, San Francisco, Dept. of

Family and Community Medicine

Direct Access to Housing- 1500 units in 33 buildingsTailor housing to needs of individual

Initially SRO, now new buildingsPriority to people with multiple disabilities93% with Axis I mental illnessAt least 18% HIV+

SF Health Dept’s Housing

Must have longitudinal professional relationshipClinical Referral FormPrioritized to house highest usersMatch services to need50% of income towards rent- 3rd party payeeGreater demand than supply

25 new applicants/wk20 vacancies/month700 people in wait pool

Wait times unpredictable

Referring to DAH

DAH Portfolio

•

253 286604 678 704 704 878

0 0

177 247 339

689

020040060080010001200140016001800

99-00 2001-2 2003-4 2005-6 2007-8 2009-10

2011-2015

NewMaster-lease

The more beautiful the housing the better the outcome

The more beautiful the housing the better the outcome- Windsor

The more beautiful the housing the better the outcome- Plaza

The more beautiful the housing the better the outcome- Mission Creek

The more beautiful the housing the better the outcome- Richardson

The more beautiful the housing the better the outcome- Kelly Cullen Community

The more beautiful the housing the better the outcome- Kelly Cullen Community

The more beautiful the housing the better the outcome- Kelly Cullen Community

Plaza High Utilizer Study

• 106 Chronically homeless adults• Cost year before housing: $3,132,856 • Cost year after housing: $906,228• Reduction in healthcare costs: $2,226,568 • Cost of program: $1.1million/year• Reduction in public cost in first year: $1.1 million• More than 90% of reduction

among 15 tenants who cost more than $50,000/year prior to being housed

• Ranking of housing from worst to best housing• Private bath better than shared bath• New building better than renovated• Nursing better than no nursing• Senior better than non-senior

EvaluationQuality of Housing and Outcome

Windsor Empress LeNain PBI CCR West Folsom Dore

Plaza 149 Mason

990 Polk Mission Creek

0.0

5.0

10.0

15.0

20.0

25.0

30.0

R² = 0.76418262009445

Move-out not death

Move-out not deathLinear (Move-out not death)Linear (Move-out not death)

Windsor Empress LeNain PBI CCR West Folsom Dore Plaza 149 Mason 990 Polk Mission Creek

7.6

3.5

6.8

3.9

5.3

2.7

5.0

3.5

2.5

4.0

3.1

R² = 0.388887624467414

Death by Quality of Housing%death

Death Rate/year0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Death rate Le Nain vs. Mission Creek 2006-2011

Le Nain death %MCSC death %

The more beautiful the housing the better the outcome

NYC: 90,000 in locked institutions in1955Homeless advocates focused on economic conditions, not illness

Episodic vs. Chronically homelessTiming of offering PSH?

Impact of trauma

Homelessness in US

POPULATION SNAPSHOT

Veteran PIT Counts, 2009-2012

* CoCs only required to conduct a new count of unsheltered homelessness in odd numbered years; in 2012, only 32% of CoCs opted not to do a new unsheltered count, providing an incomplete picture of trends in the number of unsheltered homeless VeteransSource: PIT data, 2009 - 2012

2009 2010 2011 2012 -

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

75,609 76,329

67,495 62,619

43,409 43,437 40,033

35,143

32,200 32,892 27,462 27,476

Total VeteransSheltered VeteransUnsheltered Veterans

Num

ber o

f Vet

eran

s

*

2010 2011 2012 2013 2014 20150

100

200

300

400

500

600

HennepinLexingtonTacomaFort WorthBirmingham

Measured

-------Projected

______

Number of Homeless Veterans in 5 Communities with Greater than 40% reduction 2010-2012

2005 2006 2007 2008 2009 2010 2011 20120

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

0.60%

0.70%

13,69013,362

11,970

14,375

15,525 15,642

14,351

16,522

5,5655,910

5,000

6,7857,100 7,105

6,440

7,390

1,932 1,9141,530 1,470 1,400

812 601 542

0.60%

0.52%

0.46%

0.53%

0.57%0.56%

0.52%

0.60%

Utah Homeless Point-In-Time Count: 2005-2012

Annualized Total Count Number of Persons in Families Number of Chronically Homeless Persons Total Homeless Persons as % of Total Population

Source: 2012 Annualized Utah Homeless Point-In-Time Count

2005 2006 2007 2008 2009 2010 2011 20120

500

1,000

1,500

2,000

2,500

0%

2%

4%

6%

8%

10%

12%

14%

16%

1,932

1,9141,530

1,470 1,400

812601

542

14%14%

13%

10%

9%

5%4%

3%

Utah Annualized Chronic Homeless Count: 2005-2012

Chronic Count% Chronic of Total Homeless Persons

Source: 2012 Utah Homeless Point-In-Time Count

2009 2010 2011 20120

50

100

150

200

250

300267

224

177

126

Veterans in Minneapolis/Hennepin County 2009 - 2011

total veterans

2009 2010 2011 2012

775 779

566

351

Point-in-time count for Minneapolis/Hennepin County Con-tinuum

total chronic homeless

21.8424.26

17.59

10.36

Common values and philosophy of practice, strong leadership, housing first

TargetingHigh level of communication (HIPPA busters)Use of data to inform policy and measure success

Common aspects of “positive outliers”

Common values and philosophy of practice, strong leadership, housing first

TargetingHigh level of communication (HIPPA busters)Use of data to inform policy and measure success

Common aspects of “positive outliers”

Overcoming “wrong pocket” problemProving value of supportive housingMoving forward from data to expansionReplicating positive outliers in non-VA populations

Next steps in movement

HOUSING AS HEALTHCAREJoshua D. Bamberger, MD, MPH

Josh.bamberger@sfdph.org

San Francisco Department of Public HealthUniversity of California, San Francisco, Dept. of

Family and Community Medicine