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✦Cross-sectorPartnership:Thecommunitybroughttogetheradiversecollaborativeofhospitals,housingagencies,healthcenters,behavioralhealthproviders,socialserviceorganizationsandgovernmentagencies.

✦Data-DrivenStrategy:Datamatchingacrossmultiplesystemswasusedtoidentifyhighutilizersduringtheearlypartofthestudy.Theprojectmovedtoreferralsbasedonautilizationthreshold.

✦Outreach,Engagement,andRecruitment:AnOutreachCoordinatorprovidesassertiveoutreachintohospitals,jails,institutionalandotherhomelessservicesettings.

✦Housing:Multiplepartnerscametogethertoincreaseaccesstohousing.PSHunits,owned,andoperatedbyAvalonHousing,areprioritizedforprojectparticipants.Thelocalpublichousingauthority(PHA)providespublichousingunitsandHousingChoiceVouchers.TwolocalhousingprovidersprovideShelterPlusCaresubsidies.

✦IntegratedHealthandHousingServices:AstrongpartnershipbetweenAvalonHousing,hospitalsystems,andthelocalhealthcenterelevatesinpatientcarecoordinationandaccesstoprimarycare.

✦Rigorous3rdPartyEvaluation:ThisprojectisbeingindependentlyevaluatedbyNYUusingacontrolandinterventiongroup,aprocessevaluationwithannualsitevisitsandkeypartnerinterviews.

✦BuildingCommunity:Communitybuildingisanintegralaspectoftheservicesmodelwithanaverageof75communityeventseachmonth.

✦ Bringtogethercommunitypartnersfromavarietyofsectorstoconnectfrequentuserstohousing,healthcare,andcarecoordinationisboththegoalandlastingoutcomeoftheFrequentUsersSystemsEngagement(FUSE)initiativeinWashtenawCounty,Michigan–asubgranteeoftheCSH’sSocialInnovation.Otherhealthcenters,housingandserviceproviderscanlearnandreplicatethesecoordinationefforts.AvalonHousing,apermanentsupportiveHousingFirstprovider,istheleadagencyforthisinitiative.TheyworkcloselywiththeUniversityofMichiganHealthSystem,St.JosephMercyHealthSystem,PackardHealth(thelocalHealthCenterProgramgrantee),CommunityMentalHealth,theShelterAssociation,theAnnArborHousingCommission,andotherserviceproviders.

✦ TheFUSEprojecttargetsindividualswhomeetthresholdcriteriaforfrequentutilizationofcrisissystems,includinghomelessnessorhousinginstability,lowincome,behavioralhealthconditions,chronicphysicalhealthconditions,andfrequentemergencyroomutilizationand/orhospitalizations.

✦ Byprovidinghousingnavigation,intensivecasemanagement,andcarecoordinationforprimaryandbehavioralhealthservices,theFUSEprojectintendstodemonstrateareductioninuseofemergencysystems,improvedhealthoutcomesforfragileindividuals,andcostsavingsacrossmultiplesystems.

✦ Challenges:AffordablehousingresourcesarelimitedinWashtenawCounty’shighrentalmarket,andstatebudgetcutshaveresultedinareductionofavailablevouchers.TheresearchstudywasdelayedbyunanticipatedworkneededtomeetInstitutionalReviewBoard(IRB)requirements,whichinturndelayedthestartoftheprogram.Sustainablefundingalsoremainsachallenge.

✦ Opportunities:Avalon’s20yearsofPSHexperience,andWashtenaw’sexistingproviderrelationshipsthroughtheContinuumofCareandotherlocalcoordinatingbodiesprovidedasolidfoundationtobuildon.Effectivecommunityprioritizationthroughacentralaccesspointmadeforclearandeffectivetargeting.

INITIATIVEOVERVIEW

Frequent Users Systems Engagement (FUSE)

Washtenaw County, MI | April 2016

KEYFEATURES&INNOVATIONS

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History ✦ AvalonHousinghasbeenprovidingpermanentsupportivehousingforovertwentyyearsandhasastronghistoryof

activismandadvocacyinthecommunity.✦ SystemslevelcollaborationwiththeWashtenawHousingAllianceandstrongmentalhealthadvocacyfromCommunity

MentalHealth'sstreetoutreachteamhelpedlaythegroundworkforthisinitiativetosucceed.✦ AtthestartoftheFUSEproject,thepreviousleadagencyhadaprograminplacewiththelocalambulanceserviceto

providecasemanagementtofrequentutilizers.✦ Existingsupportivehousingteamshadbroughttolighttheentanglementofthehealthcareandhomelessservicesystems,

andthelackofcommunicationandcoordinationacrosssystems.WashtenawCountywaswellpositionedtoparticipateintheSocialInnovationFundopportunityandshareexperiencewiththeotherthreeresearchsites.

✦ TherelationshipwiththeUniversityofMichiganComplexCareManagementProgramhelpedjump-starttheformalcollaborationandthedata-driventargetingprocesswithU-Mandotherpartners.

Target Population

Approach TheWashtenawCountyFUSEinitiativeadoptedateam-basedapproachtocarewithintensivecasemanagementservingasanintegralcomponent.Theteammeetsweeklytodiscussincomingreferrals,careplansforcurrentclients,andcomplexcases.FUSEclientswereinitiallyidentifiedthroughadatamatchprocesswiththetwohospitalsystems,homelessshelterproviders,andbehavioralhealthproviderstocreatearecruitmentlist.Nowinitsfourthyear,theprojecthasmovedtoadirectreferralsystemusingtheutilizationthresholdlistedabove.

Onceidentified,theoutreachcoordinatorworkstoengagetheindividual,locatehousing,andassiststheparticipantthroughmove-in,wheretheyareassignedacasemanager.CaseManagersmaintainlowcaseloads,withanaverageof1:20,balancedbytheacuityofclientneed.Theycompleteacomprehensiveassessment,andlinkthemtoneededsupportssuchasmedicationmanagement,legaladvocacy,employmentandeducation.CaseManagerscoordinatecaretoaddressphysicalandbehavioralhealthneeds,linkingclientstoaprimarycareproviderandassistingwithnavigationofmentalhealthandsubstanceabusetreatmentsystems.Theteamistrainedonevidence-basedpracticessuchasmotivationalinterviewing,assertiveoutreach,traumainformedcare,housing-firstandharmreductionapproaches.

PackardHealth,theHealthCenterpartner,providescomprehensiveprimarycareandintegratedservicesthroughtheirPatientCenteredMedicalHomemodelandisworkingtoprovideonsiteservicestoFUSEparticipants.PackardalsodesignatedanursepractitionertoparticipateontheFUSEcareteam,whichhelpstocreateawarmhand-offintoprimarycarefromhospitalandhousingpartners.TheirparticipationisinrecognitionofthevalueofstabilizinghealthandprovidingpreventativecareinadditiontostablehousingtopreventfutureERvisitsandhospitalizations.

Frequent Users Systems Engagement: Washtenaw County, MI

INITIATIVEDETAILS

✦ Verylowincome

✦ Haveadiagnosedmentalhealthconditionorsubstanceusedisorder

✦ Oneormorechronicphysicalhealthcondition

✦ Homelessorinpersistenthousingcrisis

✦ Highutilizersofcrisishealthservices-definedas(1)8ormoreERvisitsor(2)1ormorehospitalizations&3ERvisitsinlastyear

Housing

IntensiveCaseManagement

Identify&LocateParticipant

HousingNavigation

OutreachCoordinator

HealthSystemCoordination-PCP,HospitalBehavioralHealthPartnerships

Employment&EducationSupport24/7CrisisIntervention

Landlord/TenantMediation

Referrals

CoordinatedAccess

Hospitals

DataMatch010101010101010101010101010101010101010101010

101010101010101010101010101010101010101010101

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Goals

Outcomes

OUTCOMES

Frequent Users Systems Engagement: Washtenaw County, MI

“PriortoFUSEIselfmedicated.Iwasgettingkickedoutofeverywhere.ItriedtotakemyselfoutacoupleoftimesandthenImetmyFUSE

worker.Shehashelpedmesomuch.I’vebeenhousedforalmostthreeyearsnow.IthinktheFUSEprogramissoawesome.Iwouldn’tchange

anything.EventhoughbadstuffhashappenedI’mnotahotmessanymore.Idon’tdrinklikeIusedto.Idon’thavetogototheemergencyroomalotanymore.IfIdon’tanswermydoorIget15milliontextsfrom

myworker.I’minamuchbetterplace.FUSE,theyrock,theydo.

BeingwithFUSEIdon’tgotothehospitalanymore.IhavearegulardoctorIgoandsee.I’vegainedweightsoI’malittlehealthier.Ilikethefactthattheycareabouthealthinessandaboutwhatwethink.Theone

ononefacetofacewithusmakesadifference.”

-Lamethia,FUSEParticipant

SystemLevel:

ReducePublic&PrivateHealthCareCosts

BreakDownSystemicBarrierstoCoordinatingCare

IncreaseVisibility,Awareness,&Understanding

BuildaSolidBasetoEngageLocalandStateLevel

PolicymakerstoStimulateSystemChangesthatWork

TowardSustaining&DisseminatingtheModelofCare

BreakDownBarrierstoRapidAccesstoHousing

IntegrateAffordableHousingResourceswithHealthCare

SystemDecreaseMortalityRates

ProgramLevel:

ReduceUtilizationofDetoxFacilities,Shelters,Jails,etc.

ReduceEmergencyRoomUtilization

ReduceMedicalandPsychiatricInpatient

AdmissionsandHospitalDays

ParticipantLevel:

ReduceSubstanceUse

ImprovePhysicalHealthbyIncreasedPrimaryCareUtilization

ExitHomelessness&IncreaseHousingStability

ImproveMentalHealthbyIncreasedServiceEngagement

Quantitative:

87%EnrolledinPrimaryCare

ReductioninInappropriateERandHospitalUsage(In20154thQuarter:46%participantshadnoER

utilization,56%participantshadnoinpatientstays)

HighHousingRetentionRate:81%IncludingNegativeExits(Hospitalization,Incarceration,Evictions,Deceased)101Housed,4Evictions

Qualitative:

ImprovedQualityof

Life

IncreasedBodyofEvidence,Awareness,andRecognitionLocallyandattheStateLevelRegardingPSHModelandits

Impact

ImprovedSystemsLevel

CareCoordination

BridgedGapsinPreviously

FragmentedServiceSystems

WiderAcceptanceofHarmReductionOrientedCareattheCommunity

Level

Multidisciplinary,Cross-systemCareTeamEstablished

Challenges ✦ Sequestration:Thenationalbudgetsequestrationin2013impactedtheabilityofthesitetoaccessHousingChoiceVouchersfrom

thelocalPHAwhenthatresourcedecreased.Thismeantvoucherswerenotavailableforaperiodoftimeintheearlystartupphaseoftheproject.However,theyovercamethischallengebyleveragingotherstateandlocalhousingresources.

✦ HousingMarket:WashtenawCountyhasahighrentmarket.Thefairmarketrentlocallyissometimeshigherthanthevoucherlimit.Thereisalowvacancyrateinthemarket,makinglandlordrecruitmentachallenge.

✦ HarmReduction:Ashiftinthepredominantphilosophyofcarewasneededinordertoimplementharmreductionorientedcareatthecommunitylevel.WashtenawCountyhaslimitedaccesstosubstanceuseservicesforindividualswithsubstanceusedisorderswhoareinapre-contemplativestageofchange.

✦ IRBProcess:ThelocalhealthsystemsrequiredIRBapprovalforboththeevaluationanddatamatch.IRBapprovalandsubsequentamendmentscreatedprogrammaticdelaysandunplannedadministrativeburden.

✦ Medicaid:LimitedMedicaidbillingoptionscreatecomplexities.AvalonHousingisacontracted“CommunityLivingSupports”providerwithCommunityMentalHealth(CMH),Washtenaw.UnderthisarrangementthereisonlyoneMedicaidcodethatAvaloncanbillunder.TobillunderthiscodeindividualshavetobeopentoCommunityMentalHealthandmeetmedicalnecessityforthisservice.Whileitishelpfultohavethisstablefundingstreamtosupportsomeoftheirclients,billableservicescoveredunderthecodedoesnotadequatelycapturethescopeofwork.

✦ HUDFunding:HUDfundingprioritizeschronicallyhomelesspopulation.ThetargetpopulationwasbroaderandcreatedlimitationsontheWashtenawCounty’shousingoptionsforthosewhodonotmeetthesecriteria.

✦ ComplexNeeds:Thetargetpopulationexperiencescomplexmedicalandbehavioralhealthneedsthatsomestaffwerenotequippedtohandle.Thecommunityisworkingonexpandingtheskillsetofstafftomeetcomplexneedspopulation.

Opportunities ✦ Zero:2016:BeingaZero:2016 communityhelpedtoimproveWashtenawCounty’scoordinatedassessmentprocess.1

✦ EstablishedPSHProgram:AvalonHousing’s20yearhistoryofprovidingPSHenabledtheFUSEinitiativetobuildonawellestablished,successfulprogrammodelandinfrastructure.

✦ Collaboration:Dedicatedcommitmentsfrompartneragencieshelpedtocreateatruecrosssystemscollaborativeapproach.

✦ CareModel:Eachhealthsystemhadanestablishedcaremodel,whichallowedfornaturalpartnershipstodevelop.Forexample,theUniversityofMichiganHealthSystemcreatedaComplexCareManagementProgram,whichcoordinateswithprimarycare,communityproviders,andsupportagenciestoservepatientswithahighlevelofneed.

✦ PHAPartner:AvalonHousinghasastrongpartnershipwithlocalPublicHousingAuthority.ThePHAhascreatedapreferenceforpeopleexperiencinghomelessnessforpermanenthousingandrenovatedanexistingsinglesitehousingcomplex.

✦ LeveragingResources:TheFUSEinitiativehasallowedthecommunitytoleveragenewfundingsourcesandhousingresources,includingdirectfinancialassistancefromoneofthehealthsystems,whichwillserveasanopportunitymovingforward.

Zero:2016 is a Community Solutions Initiative involving communities around the country working to end veteran and chronic homelessness. 1

https://cmtysolutions.org/what-we-do/zero-2016 �4

Frequent Users Systems Engagement: Washtenaw County, MI

CHALLENGESANDOPPORTUNITIES

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Avalon Housing KeyRole:AvalonHousingistheleadagencyforthisproject.TheyareasupportivehousingandserviceproviderandprovidecasemanagementtoFUSEparticipants. Hospital Partners: University of Michigan Health System - Complex Care Management Program & St. Joseph Mercy Health System Program for the Uninsured KeyRole:TwolocalhospitalsystemsworkwithcasemanagerstocoordinatecareandhealthsystemlinkagesfortheFUSEpopulation. Washtenaw County Community Mental Health KeyRole:WCCMHisthementalhealthservicesprovidertotheFUSEpopulation.Theyprovidementalhealthservicestoadultswithasevereandpersistentmentalillness,childrenwithasevereemotionaldisturbance,andindividualswithadevelopmentaldisability.

Washtenaw Health Initiative KeyRole:FUSEisanadoptedprogramoftheWashtenawHealthInitiative,thatprovidescountywidecollaborationfocusedonimprovedaccesstocareandfundraisesfortheFUSEinitiative. Packard Health KeyRole:FUSEprogramparticipantsarelinkedtoprovidersatPackardHealth,thelocalhealthcenterprogramgrantee,whichprovidesprimarycaretothemajorityofparticipantsandwilldesignateanursepractitionertobepartofthecareteam. Washtenaw Public Health and Washtenaw Housing Alliance KeyRole:BoththeWashtenawPublicHealthandWashtenawHousingAllianceassistedwithadvocacyandcommunityresourceprioritizationfortheFUSEinitiative. Ann Arbor Housing Commission KeyRole:AnnArborHousingCommissionprovidesHousingChoiceVouchersandpublichousingunitstotheFUSEprogram. Michigan Ability Partners and Shelter Association of Washtenaw County KeyRole:MichiganAbilityPartnersandtheshelterassociationprovideShelterPlusCarerentalsubsidiestotheFUSEprogram.

Frequent Users Systems Engagement: Washtenaw County, MI

INITIATIVEPARTNERS

BeforeAvalon,lifewashard,neverknowingwhereyouwillstayorwhatyouwilleat.Thinking,whereIcangotomeetmykids,howcanIstaysafe?In2011,afterlosingmyjobasanLPN,Ibecamehomeless.IhadstarteddrinkingheavilyandmyhusbandandIstruggledtofindplacestostay.Wewouldbouncefromfamilymembertofamilymember.Thenmyhusbandcommittedsuicide;thatwasayearago.AfterthatIlivedintents,theshelter,prettymuchanywhereIcouldstay.Tobehomeless,feelscrappy-

Thenyougetusedtoit.Itconsumesyourentireday.Ittakeshoursandhoursthinkingaboutwhereyouaregoingtolive,whereyouaregoingtostaysafe,whereyouaregoingtoeat.You’llthink—“HowdoImakethingsbetter”—butyouliveinthemoment.Somuchso,thereisnoplanningahead.Youdon’tknowwhatyouaregoingtowear,whereyouwillwashyourclothes,howyouaregoingtoseeyourkids.Thesethoughtsconsumeyou.Ihavethreechildren,onediedofSIDS,itwasverytraumatizing.TheUniversityofMichiganhospitalwastryingtohelpmestaysoberbecauseIwasspendingtime,alotoftime,intheEmergencyRoom.Butbeinghomelessishardbecauseyouwanttonumbupandnotfeeleverythingyoudofeel.Imeanwhowouldn’twanttofallasleepinsteadofyourmindracingallnightthinking.…”WhatamIgoingtodotomorrow?”

ThatiswhenIgotthecalltocometoAvalon.Theyareworkingwiththehospitals,PORT,andCSStohelp100peoplegetcounselingandgetoffthestreets.ItiscalledtheFUSEProgramandtheygiveyouhelpwithyourmedicalneeds,support,andhousing.

SinceIhavebeenhereatAvalon,Igettoseemykidsregularly.Igettoseemydoctorregularly,IcaneatwhenIwantandalltheresourcesIneedarehere.Mycaseworkerhashelpedmewithsomuch,morethanshewouldeveracknowledge.Shehelpedmeclearupoldwarrantsfromnotbeingabletopaytickets.Thosearethetypesofissuesthatkeeppeoplehomeless.

ThingshavegottenbetterandIhaveasecondjobnow.Littlebylittle,Igetbetter.ForalongtimeIfeltlikemylifewasnothingbutturmoilandIwasonaroadtoself-destructionandprobablydeath.Now,it’slikeIhaveashot,IgettomakeachoiceintheroadandIchooseAvalon—it’slikemybigsteppingstone.It’sgivenmetheopportunitytocomeupinlifeandnotdown.TheygivemetheresourcesthatIneed.Mylifeisnowprettygood.

KRISTIN’SSTORY

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Funding Sources Fundingfromthesesourcesisusedtocovercasemanagementanddata&oversight.

*SIFfundingmustbematchedbythecommunity.

Costs Savings Resultspending.

Program Costs

TotalAnnualCostwithRentalAssistance:$11,394

FUSE

St.JosephMercyHealthSystem$84,500

CommunityMentalHealth,WashtenawCounty

$102,000

SocialInnovationFund$200,000

WashtenawCountyCoordinatedFunders

$53,438

FINANCES

Frequent Users Systems Engagement: Washtenaw County, MI

0

3000

6000

9000

12000$250

$1,105

$3,809

$6,230RentalSubsidiesCaseManagementandHousingNavigationDataandOversightTransportation

ProgramCosts(PerClient)

HousingResources:✦ AvalonHousing:

• PSHUnits

✦ AnnArborHousingCommission(PHA):• PublicHousingUnits• HousingChoiceVouchers

✦ TwoLocalHousingProviders:• ShelterPlusCareSubsidies

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Frequent Users Systems Engagement: Washtenaw County, MI

CSHtransformshowcommunitiesusehousingsolutionstoimprovethelivesofthemostvulnerablepeople.Weoffercapital,expertise,informationandinnovationthatallowourpartnerstousesupportivehousingtoachievestability,strengthandsuccessforthepeopleinmostneed.CSHblendsover20yearsofexperienceanddedicationwithapracticalandentrepreneurialspirit,makingusthesourceforhousingsolutions.CSHisanindustryleaderwithnationalinfluenceanddeepconnectionsinagrowingnumberoflocal

communities.WeareheadquarteredinNewYorkCitywithstaffstationedinmorethan20locationsaroundthecountry.Visitcsh.orgtolearnhowCSHhasandcanmakeadifferencewhereyoulive.

ABOUTCSH

TheNationalHealthCarefortheHomelessCouncilisanetworkofdoctors,nurses,socialworkers,patients,andadvocateswhosharethemissiontoeliminatehomelessness.Since1986wehavebeentheleadingorganizationtocallforcomprehensivehealthcareandsecurehousingforall.Weproduceleadingresearchinthefieldandprovidethehighestleveloftrainingandresourcesrelatedtocare

forpersonsexperiencinghomelessness.Wecollaboratewithgovernmentagenciesandprivateinstitutionsinordertosolvecomplexproblemsassociatedwithhomelessness.Additionally,weprovidesupporttopubliclyfundedhealthcentersandHealthCarefortheHomelessprogramsinall50states.Visitnhchc.orgtolearnmore.

ABOUTNHCHC

AllphotosdepictstafforconsumersreceivingservicesfromtheWashtenawCountyFUSEprogram.

“TheFUSEprogramtakesmetoallmydoctors,checksinonme3-5timesaweek.NomatterhowmuchhelpIneededtheyalwayshelpedme.I’ve

beenhousedforalittleoverayearnowandI’mveryhappytobeonmyown.Idon’tknowwhatI’ddowithoutmy

FUSEworker.Shetriestomakeherselfavailableforeverything.She’sveryunderstanding.TherewasnosupportorcomparabletowhatFUSEprovides

beforethis.”

-Carol,FUSEParticipant

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Frequent Users Systems Engagement: Washtenaw County, MI

“ThisprojectwassupportedbytheHealthResourcesandServicesAdministration(HRSA)oftheU.S.DepartmentofHealthandHumanServices(HHS)undercooperativeagreementnumber#U30CS26935,

TrainingandTechnicalAssistanceNationalCooperativeAgreement(NCA)for$325,000with0%ofthetotalNCAprojectfinancedwithnon-federalsources.Thisinformationorcontentandconclusionsarethoseof

theauthorandshouldnotbeconstruedastheofficialpositionorpolicyof,norshouldanyendorsementsbeinferredbyHRSA,HHSortheU.S.Government.”