EXAMINING THE EFFECTIVENESS OF THE HOUSING FIRST MODEL IN A SAMPLE OF HIGH UTILIZERS

Presented by:

Francisco Quintana, PhDClinical Supervisor/Coordinator

Kiva Transitional Housing Clinical Assistant Professor

FIU Dept. Of Psychiatry and Behavioral Health

Objectives

• 1.Statistic on Homelessness • 2.Factors Contributing to Homelessness • 3. Issues Faced by Individual Who are Homeless • 4. Super-Utilizers• 5. Housing First • 6. Pilot Study • 7. Conclusions • 8. Discussion

Conflicts of Interests

• Francisco J. Quintana, Ph.D.

No conflict of interest

Homeless Statistics

• Homeless is rising• Increased for the second consecutive year

• Point in Time Count 2018 (The 2018 Annual Homeless Assessment Report to Congress)• Across the US, 553,000 people were

experiencing homelessness • In Florida, this number is 31, 030

• 2, 757 were family households• 2, 543 were Vets• 1, 892 were unaccompanied young adults

(aged 18-24)• 5, 302 were individual experiencing chronic

homelessness

Homelessness and Its Causes

• Social-economical-political factors• Economic downturns • Poverty• Low paying jobs• Cuts in public assistance programs • Lack of affordable housing

Homelessness and Its Causes

• Personal Factors• Mental illness or substance abuse issues • Health problems• Functional issues • Little or no support systems

Mental Illness

• Homeless Individuals experience higher rates of psychiatric disabilities compared to the general population (Fischer & Breakey, 1991).• 25% homeless are believed to have a SMI (AHAR, 2017)

• High lifetime prevalence rates for schizophrenia, bipolar disorder, and depression (Herman, Susser, & Struening, 1998)

• Alarming high rates of suicidal ideation (66%) and suicide attempts (34%; Eynan et al., 2002)

Health Problems

• Percentage • More than 8 out of 10 people (83%) reported

having a chronic condition (St. Michael’s Hospital, 2011)

• Other studies: incidence of chronic disease is 2x higher an general population

• Chronic Health Conditions Reported• Heart disease • Diabetes • High blood pressure• Chronic obstructive pulmonary disease

• What Came First?

Maria: Case Example

• DEMOGRAPHICS • 52 year old Hispanic female• Primary Dx of Major

Depressive Disorder • Long history of

polysubstance abuse • History of trauma • Multiple medical conditions

• Type 2 diabetes (insulin-dependent)

• Overweight • Hypertension• Partially blindness

PROBLEM REPORTED WHILE HOMELESS• Unemployed• No medical benefits• Difficulties controlling

weight• Eating healthy• Storing insulin• Buying glucose test

strips• Attending

appointments

Disability/Functional Impairments • Functional Impairments

• Percentage• 30% in persons over 50 years of age• Basic self-care actives (e.g., bathing

and dressing)• Can lead to issues with

accessing services, finances, living independently, and finding a job

• Unknown if it is transient or persistent

Who is a high-utilizer (HU)?

• Definition varies• Use the public services with

extraordinary frequency• Have complex co-occurring

mental and physical conditions• Struggle with socioeconomic

challenges and have poor access to care.

Socioeconomic Challenges

• Poverty• Unemployment • Food, Housing,

and transportation insecurity

• Lack of education

Interventions to End Homelessness

• Housing First (HF) Model• Housing First

• 1. Aims Assist patients in accessing PSH (initial step)• 2. Housing not attached or contingent on Treatment • 3. HF including ongoing support (case management,

psychiatry)• Outcomes

• Reductions in public service utilization(e.g., jails, shelters)

• Saves money• Does it improve health, psychiatric

symptoms, and functional impairments?

Housing First Outcomes: A Longitudinal Pilot Study of Individuals who Are Homeless and are Serviced by Citrus Health Network (CHN)

• Add-On Pilot Study• Study approved by FIU Institutional Review Board

• Purpose of Study• Study Aim

• Evaluate the effectiveness of HF in improving outcomes overtime in a high utilizer homeless population with mental illness who are offered PSH in Miami-Date County

• Hypothesis• We hypothesize that participants in HF would show improvements over

the course of a year in psychiatric symptoms, disability, daily functioning, and self-stigma

Methods

• Design: Within Subjects Design, 1 year longitudinal study

BaselineInitial Assessment

Year 1Reassessment

Pilot Study

• Diagnoses• Primary Dx: Schizo,

Depression, and Bipolar • 40% of participants had

with SMI had SU• Medical conditions:

18.8%

• Participants (n=32)• Age: 52.1• Gender: Male 87.5%• Race

• White Hisp: 56%• Black Non-Hisp: 38%• Other: 6%

• Months Homeless: 91.2

Demographics

Results• Individual Measures

• Disability• Standing for long periods of time• Walking for long distances • Emotional stress due to health problems

• Psychiatric Symptoms • High anxiety

• Self-Stigma• Levels similar to a population living

with mental illness • Functional Capacity

• Functional deficits, but within the limits of being able to live independently

Correlations

• Disability associated with psychiatric symptoms and self stigma at baseline and 1 year after receiving housing.

• Functional capacity was not significantly related to none of the other outcomes at baseline or 1 year assessment

Paired T-tests: Comparing Baseline and 1 Year Assessment

Results Cont.

• Additional exploratory regression models were built to examine if any of the outcome variables in the study could serve as predictor variables.

• Regression Analyses• Disability (WHODAS score) predicted psychiatric

symptoms (BSI), p<.01. • Self-stigma predict depression (BSI Subscale)

symptom, p<.05,• Effect sizes were classified as large (Cohen’s f2)

Discussion

• Results supports prior research that homelessness is correlated with higher rates of psychiatric, substance-use disorders, and functional impairments.

• Results indicate that disability, psychiatric symptoms, and self-stigma are interconnected.

• HF appears to improve disability, functioning, and psychiatric symptoms in high utilizers (at least within a year period).

• Self-stigma should be addressed via psych interventions

Coalition Lift Project• Findings: 1 year interim report

• Most remained housed: >80%• Significant cost savings (overall): ~56% • Medicaid hospital costs decreased by 73%

• Suggests improved health

• Challenges• Mental health treatment issues

• Initiation • Compliance

• Reluctance to address substance use• Antisocial Behavior

Questions?

Acknowledgments • Important Contributors

• Adriana Foster, MD• Michelle Trieu, MD• Angela Mooss, PhD• Julio Machado, MD• Aniuska Luna, PhD• Randel Martin, MS• Simran Sandhu, MD

• Baseline Data Obtained From:• Trieu M., Quintana F., Foster A., Machado J., Luna AM., Martin R., Mooss

A., Housing First Outcomes: A Longitudinal Pilot Study of Disability, Psychiatric Symptoms, Daily Functioning, and Self-Stigma in Homeless Individuals, poster, American Psychiatric Association Annual Meeting, May 2019, San Francisco, CA.