Home and Healthy for Good
Home & Healthy for Good is a statewide initiative providing housing, support services, and advocacy for individuals experiencing chronic homelessness. Coordinated by the Massachusetts Housing and Shelter Alliance (MHSA), the program provides housing placement and supportive services based on Housing First principles through a network of community-based providers. Particularly noteworthy is the program’s annual tracking of cost impacts related to the use of public services before and after participants’ entry into housing.
Problem or Challenge:
Traditionally, the response to homelessness in Massachusetts was the provision of emergency shelter, where participants were moved through a continuum of care based on their compliance with a sequential service program. For individuals experiencing chronic homelessness, this approach was largely ineffective due to the complex interplay of disabling medical conditions, mental illness, and substance use disorders that interfere with their ability to comply with services.
Home & Healthy for Good was created by MHSA (a public policy advocacy organization) to turn the old model on its head through a focus on immediate placement into permanent supportive housing. In 2007, the Massachusetts Legislature passed a line item in the state budget to fund the program as a statewide Housing First pilot designating MHSA as administrator of the funds. Since that time, Home & Healthy for Good has housed over 500 individuals who were formerly chronically homeless.
Home & Healthy for Good is an initiative with four components:
Housing and services delivered by local providers using a Housing First approach
Training and assistance through MHSA to Home & Healthy for Good -funded agencies and front-line case managers
A database managed by MHSA and used to evaluate program outcomes and performance
Advocacy to direct existing resources toward permanent supportive housing
Through the Home & Healthy for Good program, a network of 12 agencies based in ten communities provides housing and support services to individuals experiencing chronic homelessness. The housing may be scattered-site apartments or buildings that offer site-based permanent supportive housing. About 60 percent of participants are housed in project-based single room occupancy units or shared living arrangements where each tenant has a private bedroom and shares bathroom, kitchen, and laundry space with other tenants. About 40 percent of Home & Healthy for Good participants live in apartments scattered throughout neighborhoods.
Participants in Home & Healthy for Good are identified by the local agencies which provide low threshold access to housing using a Housing First approach. While all newly identified participants are experiencing chronic homelessness, more than one quarter of participants are street dwellers who were staying outside prior to moving into housing. Their average length of homelessness is five years.
Participants work closely with a case manager to access a broad range of services, including medical and mental health care, substance abuse treatment, and vocational training. The use of these services, however, is not a condition of ongoing tenancy. As time in permanent housing increases, healthcare service use typically shifts from frequent use of emergency rooms and inpatient hospitalizations to participation in primary medical and mental health care. As a result, health outcomes for participants are greatly improved and medical costs decrease significantly.
Administering the program and serving as a conduit for funding
Home & Healthy for Good funds are granted by the State to MHSA as a network provider through a $1.2 million line item within the budget of the Massachusetts Department of Housing and Community Development. MHSA subgrants the funds to community providers. Home & Healthy for Good funds can be used flexibly; providers see this as one of the biggest advantages of the program. Funds can be used for support services or for leasing costs. Funded services are primarily non-clinical supports that focus on building trust, connecting the tenant to community services, and helping the tenant build skill sets around maintaining housing, income and social connections.
The vast majority of Home & Healthy for Good participants (and other individuals who experience homelessness in Massachusetts) are enrolled in MassHealth, Massachusetts’ Medicaid program. Some Home & Healthy for Good providers have been successful in funding a significant portion of the services they provide to participants through Community Support Program for People Experiencing Chronic Homelessness(CSPECH), a performance incentive project within MassHealth managed by the Massachusetts Behavioral Health Partnership. This has freed up Home & Healthy for Good dollars that would have otherwise been spent on these services, enabling the providers to expand the number of people they can serve or use Home & Healthy for Good to support leasing costs.
When Home & Healthy for Good was launched, MHSA realized its low-demand Housing First approach would represent a shift for many community-based providers, especially those that traditionally required participation in services as a condition of housing tenancy. Over the years, MHSA has engaged individuals with expertise in motivational interviewing, trauma-informed care, and other relevant methods to conduct trainings and has provided individual technical assistance and trouble-shooting support to providers. MHSA organizes a statewide meeting annually of providers involved in Home & Healthy for Good and other permanent supportive housing for peer exchange.
Collecting data for annual progress reports to the legislature
As part of Home & Healthy for Good’s authorizing legislation, the State Legislature requests that an evaluation be performed on an annual basis with a focus on the cost per participant and cost savings in state-funded programs. The first report was issued in 2006. The annual progress reports have been important to sustaining State support for the program.
New participants in Home & Healthy for Good are asked to consider enrollment in the research study and informed consent is obtained from those who agree. Participants sign MassHealth’s Permission to Share Information form so that Medicaid claims data may be analyzed. Refusal to participate in the research study does not preclude participation in Home & Healthy for Good. Medicaid analysts reviewed billing claims data in March 2009 for the 96 participants who had Medicaid eligibility in the year before and the year after moving into housing.
Case managers interview participants upon entry into housing and at one-month intervals thereafter. Interview questions pertain to demographic information, quality of life, nature of disabilities, health insurance, sources of income, and self-reported medical or other service usage. Participants have the option of refusing to answer any of these questions. From 2006 through mid-2012, case and program managers submitted the results of 8,635 participant interviews.
As of June 2012, 582 people who were chronically homeless have been housed through Home & Healthy for Good. Only three percent of these people are known to have returned to homelessness; 40 percent are still enrolled in the program, and 33 percent have moved out to other permanent housing.
In 2010, MHSA engaged Root Cause and Public Service Economics to analyze self-reported participant data and publicly-available cost averages to estimate pre- and post-housing costs. They examined participants’ use (and cost) of ambulance services, shelter and emergency rooms, and stays in prison, hospitals, and detox. The analysis revealed that Home & Healthy for Good generated a post-housing savings of roughly $4,000 per participant per year.
The Medicaid analysis conducted in 2009 revealed the following:
Annual costs of shelter, incarceration, and Medicaid-funded health care decreased from $33,648 before housing to $24,038 after housing placement, resulting in an annual savings of $9,610 per person.
On average, Medicaid costs per participant dropped by 67 percent after participants moved into housing.
Contact Info for Follow-up:
Massachusetts Housing and Shelter Alliance: www.mhsa.net. This includes links to Home & Health for Good fact sheets and annual progress/cost reports.
Evidence Based Practice: Permanent Supportive Housing
Evidence-Based Practice: Rental Housing Assistance
Evidence Based Practice: Housing First
Evidence-Based Practice: Motivational Interviewing
Model Program: Community Support Program for People Experiencing Chronic Homelessness