CENTER FOR HEALTH POLICY RESEARCH FOR A HEALTHIER INDIANA

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1 I N D I A N A CENTER FOR HEALTH POLICY RESEARCH FOR A HEALTHIER INDIANA NOVEMBER 2009 Health and Criminal Justice Expenditures of Chronically Homeless in Indianapolis: An Update Can information about the behavior patterns of the homeless help the city better serve these individuals and save tax dollars at the same time? In spring 2006, a research team at the Center for Health Policy set out to answer this question. We conducted a study to identify chronically homeless individuals who frequently use public services and to estimate the costs associated with their care. This report is an update of that study. This report, as did the original, finds that Indianapolis spends millions in... public health and public safety to serve this vulnerable population in a piecemeal fashion, with multiple emergency room visits and arrests. The report identifies programs that could serve this population more effectively and at a substantially reduced cost. Prior research suggests that homeless individuals with co-occurring substance abuse and mental health disorders face and arrests. significant challenges that have a considerable impact on the public service sector, primarily through shelter-related costs, increased utilization of emergency medical services, and frequent contact with law enforcement and the criminal justice system (Culhane, Metraux, & Hadley, 2002). This study was conducted to update the estimated public health care and criminal justice-related expenditures for serving this population in Marion County. The primary focus is on those homeless individuals who are frequent users of public services, typically homeless persons who face significant mental health and/or substance use-related challenges. While this Indianapolis spends millions in public health and public safety to serve this vulnerable population in a piecemeal fashion, with multiple emergency room visits subset of people who are homeless is not representative of all homeless people, prior studies suggest that they are a large portion of those who are most likely to remain homeless and/or are difficult to engage in services (Rosenbeck, 2000). The people in this category make up only a small proportion of the more than 750,000 homeless people in the United States, but are responsible for a large portion of the expenses incurred by the homeless because of their frequent use of public social services, including law enforcement, jails, drug clinics, psychiatric facilities, and hospital emergency rooms (Green, 2006). With one of the largest homeless populations in the state, according to the 2009 Summer Count of the Homeless, Indianapolis has an estimated 1,545 homeless individuals at any one time. Thus, it is useful to identify the major cost-drivers of this group and determine where resources are allocated to effectively tailor services for this population and ultimately reduce the costs associated with their care. Methodology Individuals were identified by outreach workers who work with homeless on the street and at shelter locations throughout the county. Outreach workers were instructed to contact homeless people who they knew or believed to have a mental illness and/or substance use disorder and who were high users of public services. Those identified as high users were then approached and asked

2 about their previous year s public service utilization, and, if their combination of emergency room visits and/or law enforcement contacts equaled six or more, they were asked to consider enrolling in the study. Before obtaining consent, information about the study was given to each individual, including any risks involved. Those individuals willing to participate and who were deemed competent to understand the risks and procedures involved in the study were then asked to sign consent forms, including a HIPAA release form. Participants were compensated with a one-week bus pass valued at $15. The average age of the 96 individuals who comprised the study sample was 45 years of age, 91 were men and 5 women, and 55 percent were African- American with the remaining 45 percent being white or other. After obtaining consent, data on the use of medical services and the criminal justice system by each individual were obtained for a 3 ½ year period. Data included the number of inpatient and outpatient health visits, and the number of arrests and number of days spent in jail by each individual. Data on health services utilization were provided for three areas of the Wishard Health system: the Emergency Department, Midtown Community Mental Health Center (Midtown), and the inpatient hospital admissions unit. Data were provided by the Regenstrief Medical Records System (RMRS) utilized by Wishard Health systems. Data on interaction with the criminal justice system were obtained using records from Marion County s Arrestee Processing Center (APC) supplied by the Marion County Justice Agency. The individuals included in this study were identified by outreach workers as having mental illness and/or substance abuse problems. We did not verify this diagnosis. It should be noted that seven of these people did not access any services in the 3 ½ year period we examined, and that a small percent of individuals generated a high percent of the costs. It should also be noted that the 2 estimates of cost do not include costs of food, shelter, clothing, etc., for these individuals. Health Services Costs With one of the largest homeless populations in the state, according to the 2009 Summer Count of the Homeless, Indianapolis has an estimated 1,545 homeless individuals at any one time. In our previous study, we obtained the charges for both outpatient (Wishard Emergency Department and Midtown Community Mental Health Center) and inpatient (Wishard Hospital) facilities of those people who had a visit during the study time period. The average annual charges over the entire time period were $3,364 per person for all homeless in the study group, compared with $8,348 per person per year for those who used services in any given year. The annual charges, updated to 2008 dollars using the Health Care Consumer Price Index, are $3,892 per person, and the updated annual costs for those who used services in any given year are $9,632. In addition to the cost of medical visits, we examined the primary diagnosis for inpatient and outpatient health care visits. Al most half (48.6 percent) of the visits had a primary treatment dia gnosis of either substance abuse or mental illness. Nearly three-quarters (72 percent) of those who accessed services, had at least one visit for substance abuse and/or mental illness. However, we cannot assume that the remaining 28 percent did not have some type of substance abuse problem and/or mental illness since only the primary diagnosis (for example, a broken leg) was recorded. Sub stance abuse or mental illness may have been secondary diagnoses. Criminal Justice Costs We analyzed the total number of encounters with the criminal justice system per year (Indianapolis Arrestee Processing Center and Indiana Department of Corrections) and the resulting charges incurred by individuals during the study time period. In 2006, each arrest was estimated to cost $750, while each day spent in jail was estimated to cost $ The costs, updated to 2008 dollars, using the Urban Consumer Price Index, are $ per arrest and $61.39 for each day in jail.

3 Criminal justice encounters had an estimated average annual cost of $1,784 per person in the study. The average total cost per person among individuals who had at least one encounter was $8,308. The updated annual charges in 2008 are $1,900 and $9,080, respectively. Combined Health and Criminal Justice Utilization and Expenditures Our findings suggest each year Marion County and the city of Indianapolis expend between $6,162 and $18,712 per year in the public health care and criminal justice system to respond to the needs of the average homeless person with mental illness and/or substance abuse problems. The low range of the estimate is calculated on costs of all participants in the study, while the high end is the average cost of those who used health care or criminal justice services in a given year. This estimate does not include any costs associated with providing food or shelter. According to the 2009 Summer Count of the Homeless, there are 593 people on the streets of Indianapolis or in the shelters who face mental illness and/or substance use-related challenges. Extrapolating the average costs estimated above to that population, public health care and criminal justice expenditures for this population in Indianapolis range from $3.7 million to $11.1 million annually; costs similar to those developed for other metropolitan areas (Culhane et al., 2002). The needs of homeless persons are not well met by repeatedly cycling in and out of jail and emergency rooms, nor does this pattern benefit taxpayers. There are options that better serve both groups. Ideas for Potential Programs These data raise important questions about whether public dollars are being spent effectively on the care of these individuals, or whether there are other options to respond to the needs of this population. There are several options that have been researched and demonstrated to be cost-effective in serving this population to keep them out of emergency rooms and jails. These options include engagement centers, the Housing First model, and intensive case management. 3

4 An engagement center can take various forms. It can be similar to Seattle s Dutch Shisler Sobering Center, where people who are alcoholic/addicted can sleep off the effects. The average stay is from 8 to 14 hours per visit and the center has food and clean clothing available. Staff are trained to recognize the common medical problems of people with chronic alcohol or drug addiction, administer emergency first aid, and transfer people in need of emergency medical care. People using the center are offered case management. Case managers can assist clients with income support, employment, housing, health care, substance abuse treatment, and the development of self-sufficiency skills. Another model is the engagement center at Maryhaven in Columbus, Ohio, which is a homeless shelter, not a treatment program. The engagement center is only for intoxicated homeless individuals. The engagement center s main purpose is to work with community agencies that provide specific services. Usually the average length of stay is three days for detoxification only. However, if a resident engages in referral services (detoxification and treatment) the stay can be extended depending on the needs of the resident. Although the Engagement Center does not specifically treat those with mental illness or a dual diagnosis, the goal is to refer to outside agencies for services (for example, Netcare for mental health evaluation for a resident). Other cities such as Milwaukee, Wisconsin, Portland, Oregon, and Wake County, North Carolina, have similar programs. One of the goals of these programs is to decrease emergency room usage and arrests for public intoxication. An engagement center can also take the form of the Serial Inebriate Program (SIP) in San Diego. SIP clients must be repeatedly arrested for being intoxicated in public, meet the definition of chronic inebriate (five police transports to the detoxification center within 30 days), and receive a guilty verdict with custody time. Judges then offer them the option to complete a treatment program instead of going to jail. The threat of jail time is intended to provide an incentive to participate in an intensive outpatient recovery program tailored to their needs. The goal is to maintain 4

5 the client in recovery (defined as more than 30 consecutive days of sobriety). According to an evaluation conducted on this program, before entering SIP, those who accepted treatment had median average monthly use and charges that were about two times higher than for those who refused services or were not offered them. After enrollment, however, regardless of treatment outcomes, the median average monthly use for all services and associated charges decreased by at least 50 percent, whereas for those who refused or were never offered treatment the median average monthly use for all services and associated charges stayed the same or increased. (Castillo et al., 2006) Housing First (HF) removes the requirement for sobriety, treatment attendance, and other barriers to housing. One of the groups that HF targets is people who are homeless with mental illness and substance abuse disorders. Providing permanent supportive housing to homeless people with psychiatric and substance use disorders reduced their use of costly hospital emergency department and inpatient services, which are publicly provided. An evaluation of a HF program in Seattle found that cost of services (health and criminal justice) decreased from $4,066 per person per month to $1,492 per month after 6 months in housing, and $958 after 12 months in housing. The HF participants also had substantial declines in drinking despite not having a requirement to stop drinking to remain housed. (Larimer et al., 2009) Once placed in housing, a homeless individual may not entirely stop using the emergency service system, but the use is reduced. A study in Massachusetts found that the average monthly cost for all services combined per each homeless individual was $2,270. The average cost per month for a person placed in housing with intensive case management was $1,104, a savings to the state of $918. HF saves Massachusetts over $11,000 per There are several options that have been research - ed and demonstrated to be cost-effective in serving this population to keep them out of emergency rooms and jails. These options include engagement centers, the Housing First model, and intensive case management. CENTER FOR HEALTH POLICY homeless person annually. (Massachusetts Housing and Shelter Alliance, 2007) In a study conducted by the University of Pennsylvania s Center for Mental Health Policy and Services Research, analysts tracked the cost of 5,000 people in New York City who were homeless for two years while they were homeless and two years after they were housed. They found that permanent and transitional housing created an average annual savings of $16,282 per person by reducing the use of public services. Seventy-two percent of savings resulted from a decline in the use of public health services, 23 percent from a decline in shelter use, and 5 percent from reduced incarceration. (Culhane et al., 2002) An analysis of 236 single adults who entered supportive housing at two San Francisco sites, Canon Kip Community House and the Lyric Hotel, examined the impact of permanent supportive housing on the use of acute care public health services by homeless people with mental illness, substance use disorder, and other disabilities. Eighty-one percent of residents remained in permanent supportive housing for at least one year. Housing placement significantly reduced the percentage of residents with an emergency department visit (53 to 37 percent), the average number of visits per person (1.94 to.86), and the total number of emergency department visits (56 percent decrease, from 457 to 202) for the sample as a whole. For hospitalizations, permanent supportive housing placement significantly reduced the likelihood of being hospitalized (19 to 11 percent) and the mean number of admissions per person (.34 to.19 admissions per resident). (Martinez & Burt, 2006) Intensive case management is demonstrated by two programs that Midtown Mental Health in Indianapolis run that were designed to serve homeless individuals with mental health concerns: Action Coalition to Ensure Stability (ACES), which is no longer funded, and Homeless Resource Team (HRT). The ACES 5

6 program provides wraparound case management services to persons with serious mental disorders and no permanent home. Community service providers formed a coalition in providing a seamless system of integrated care in helping this population with multiple needs. The HRT, located at the Horizon House, provides wraparound case management, medication evaluation, and monitoring for adults and youth who experience a chronic mental illness, addiction, or homelessness. The HRT program also assists clients who are in need of ongoing treatment interventions through the use of case management, medication management, nursing assessment, community-based care, supported employment, and group and individual therapy. The emphasis of HRT is on self-sufficiency and recovery. Both programs served the same client base, but each takes a different approach to treatment. HRT has a larger case load than ACES, an average of 35 active cases at any one time. The ACES program had higher costs per patient served, than HRT, but the ACES program did a better job of engaging and retaining clients, with many ACES clients continuing inpatient visits after many of the HRT patients have become disengaged. After 12 months, 91 percent of the ACES patients were still actively involved in treatment compared to only 39 percent of HRT patients. The ACES program also resulted in fewer inpatient visits, with only 10 percent of ACES patients needing inpatient services compared to 16 percent of HRT patients. As the above studies demonstrate, there are better ways to serve our neighbors who are homeless that will also save taxpayer s money and enable both the criminal justice and health care systems to operate more effectively. 6

7 References Castillo, E.M., Lindsay, S.P, Sturgis, K.N., Bera, S.J., & Dunford, J.V. (2006). An evaluation of the impact of San Diego s Serial Inebriate Program. California Program on Access to Care Findings. December Retrieved September 8, 2009, from Culhane, D., Metraux, S., & Hadley, T. (2002). Public service reductions associated with placement of homeless persons with severe mental illness in supportive housing. Housing Policy Debate, 13(1), Green, L. (2006). Supportive housing. In S. Isaacs & J. Knickman (Eds.), To improve health and health care, volume X (ch. 6) [Electronic version]. Princeton, NJ: The Robert Wood Johnson Foundation. Retrieved April 17, 2007, from files/publications/books/2007/anthologyx_ch06.pdf Larimer, M.E., Malone, D.K., Garner, M.D., Atkins, D.C., Burlingham, B., Lonczak, H.S., Tanzer, K.T., Ginzler, J., Clifasefi, S.L., Hobson, W.G., & Marlatt, G.A. (2009). Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA, 301(13), Martinez, T.E. & Burt, M.R. (2006). Impact of permanent supportive housing on the use of acute care health services by homeless adults. Psychiatric Services, 57, Massachusetts Housing and Shelter Alliance. (2007). Home & healthy for good: A statewide pilot Housing First program. Retrieved August 13, 2009, from reports/hhg_december_2007_final.pdf Podymow, T., Turnbull, J., Coyle, D., Yetisir, E., & Wells, G. (2006). Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol. CMAJ, 174(1). 7

8 Indiana University Center for Health Policy The Indiana University Center for Health Policy is a nonpartisan applied research organization in the School of Public and Environmental Affairs at Indiana University Purdue University Indianapolis. Researchers at CHP work on critical policy issues that affect the quality of healthcare delivery and access to healthcare. CHP is one of three applied research centers currently affiliated with the Indiana University Public Policy Institute. The other partner centers are the Center for Urban Policy and the Environment and the Center for Criminal Justice Research. This brief report was prepared by the authors under contract for the Coalition for Homelessness Intervention and Prevention. The data for this report were provided by the Regenstrief Institute, Midtown Community Mental Health Center, the Marion County Arrestee Processing Center, and the Indiana Department of Corrections. The authors wish to thank the homeless people who participated in the study and the agency staff who assisted us in compiling the data. All of the data analysis was conducted independently by the authors, and the conclusions presented in this report are those of the authors and may not reflect the views of the sponsor or the agencies which supplied data. Authors: Laura Littlepage, MPA, clinical lecturer, Indiana University School of Public and Environmental Affairs; Daniel Clendenning, MS, Research Coordinator The Coalition for Homeless Intervention and Prevention would like to thank Lilly Endowment, Inc., and the Indianapolis Foundation, an affiliate of the Central Indiana Community Foundation for significant annual support of the Coalition s programs. CENTER FOR HEALTH POLICY ADDRESS SERVICE REQUESTED Non Profit US Postage Paid Indianapolis, IN Permit No North Senate Avenue, Suite 300 Indianapolis, IN C42