Outcomes for Clients in the Metro Boston Area Receiving Services to Retain Housing under the Special Homeless Initiative Evaluation of the Special Homeless Initiative, Massachusetts Department of Mental Health Helen Levine and Tatjana Meschede Center for Social Policy, McCormack Graduate School of Policy Studies University of Massachusetts Boston Martha R. Burt Urban Institute July 2007 Urban Institute 2100 M Street, N.W. Washington, DC 20037 www.urban.org The contents of this report are the views of the authors and do not necessarily reflect the views or policies of the Massachusetts Department of Mental Health; the Center for Social Policy, McCormack Graduate School of Policy Studies, University of Massachusetts Boston; or of the Urban Institute, its trustees, or funders. CONTENTS Data Sources and Methods for Client Housing Outcomes ............................................................ 2 Metro Boston Data on Client Residential Stays ........................................................................ 3 DMH MHIS and Legacy Datasets ............................................................................................. 3 Provider Data ............................................................................................................................. 4 Results............................................................................................................................................ 4 How Long Do People Stay in HI-Supported Housing? ............................................................. 4 Looking Backward................................................................................................................. 5 Looking Forward ................................................................................................................... 5 Is DMH Still Housing the People Who Left Vinfen or BayCove’s HI-Supported Housing? ... 6 Living Situation of People Who Left HI Housing at Vinfen or BayCove............................. 6 DMH Services Participation among Those Who Left Vinfen or BayCove HI Housing ....... 7 What Is the Role of the Homeless Outreach Team? .................................................................. 7 How Does HI-Supported Housing Affect the Likelihood of Hospitalization?.......................... 8 Lessons Learned and Recommendations for the Future.............................................................. 10 Practical Matters ...................................................................................................................... 11 Outcomes for Clients in the DMH Metro Boston Area Receiving Services to Retain Housing under the Special Homeless Initiative This is the third report 1 in the Urban Institute’s evaluation of the Special Homeless Initiative (HI) of the Massachusetts Department of Mental Health (DMH, or the Department). HI is a funding stream that began in SFY 1992 and has grown to become an essential tool available to DMH for preventing and ending homelessness among its most vulnerable clients and potential clients with serious mental illness (SMI). For the best understanding of this third report as well as to understand the HI as a whole, the reader should also review the first two evaluation reports. Preventing homelessness or ending it quickly for Massachusetts residents with serious mental illness has been a strong element of DMH’s agenda for approximately two decades. DMH estimates that approximately 48,000 adults with SMI live in the Commonwealth of Massachusetts. Of these, the Department serves the most disabled and the poorest. Client incomes, mostly derived from SSI-SSDI benefits, hover around 15 percent of the area median income, and most clients are not employed. DMH homelessness efforts have been greatly strengthened since 1992, when the state passed the first legislation that appropriated funds for the Special Homeless Initiative. HI provides resources to reduce the incidence of homelessness among people with SMI. Housing development, both specifically for homeless people and more generally for people with SMI, has been a strong component of the DMH effort and the major focus of HI investment. Related aspects of DMH policies and practices include protocols for discharge planning, staff training to focus on housing issues, outreach to people with SMI living on the streets or in shelters, development of specialized shelters, and other aspects of homelessness prevention and intervention. In spring 2006, after 15 years of HI funding, DMH decided to take a formal look at what the HI has accomplished. It commissioned the overall evaluation, of which this report is a key part, to examine a range of issues and impacts. It did so to respond to growing interest by external parties in the many dimensions of the program, and also to determine the accuracy of its own operational sentiments that the HI has been working well over the years. Some interest focused on process questions such as how the HI has been run, how it fits into the larger context of departmental services and strategies, what types of projects it has supported, and how those projects are distributed around the state. These issues are addressed in the first report of this evaluation. 1 The first two reports are Martha R. Burt, “History, Principles, Context, and Approach: The Special Homeless Initiative of the Massachusetts Department of Mental Health” (Washington, DC: Urban Institute, 2007); and Tatjana Meschede, Helen Levine, and Martha R. Burt, “Housing Resources Leveraged by the Special Homeless Initiative of the Massachusetts Department of Mental Health, 1992–2006” (Washington, DC: Urban Institute, 2007). Housing Outcomes for HI Clients in the Metro Boston Area 2 The evaluation’s second report focuses on the housing-related funding that DMH staff, nonprofit providers, and other key stakeholders have been able to attract to Massachusetts to create appropriate housing for Department clients because the resources of HI were made available for residential support services, most often to fulfill the requirements of housing grants for matching service dollars. It also describes how HI funding has fit into an overall housing development strategy to help prevent or end homelessness for DMH clients or those who are eligible for DMH services by reason of the severity of their disability, and gives examples of specific projects and how the resources were assembled to create them. The present report addresses a matter most central to the HI’s purpose: client outcomes, focusing on clients served under the HI in the Metro Boston area because records there go back to before the beginning of HI and the area is home to the largest concentration of HI users. To the extent that current data allow, the report presents findings relevant to the following areas of concern to the Department: The cumulative number of persons housed and receiving supportive services paid for by HI; The tenure of these persons in housing; Use of DMH inpatient mental health facilities before and after receiving HI-related housing (other service use outcomes, including emergency admissions to psychiatric hospitals and detoxification facilities, must await receipt and analysis of Medicaid claims data from the Office of Medicaid); and A count of homeless persons with a Homeless Outreach Team (HOT) contact, and the relation of HOT contact timing to receipt of HI-related housing. A final evaluation report will focus on HI impacts on public costs, assuming that DMH is able to negotiate with the Office of Medicaid to obtain the relevant records. It will describe the cost of Medicaid-funded services avoided because HI and associated resources were able to house people and reduce their use of costly crisis services. DATA SOURCES AND METHODS FOR CLIENT HOUSING OUTCOMES In collaboration with DMH we determined to focus the consumer tracking and outcomes analysis on Department clients placed in HI housing by its Metro Boston Area Office, because the volume of clients was high and a database was in place to track housing placements. To further increase our chances of getting the most data and the most reliable data, we also agreed to approach the two major DMH providers of these services for the Metro Boston area, Vinfen and BayCove, that together provide more than half of Metro Boston’s HI beds. Based on several discussions with Vinfen and BayCove staff, we found both providers had switched from paper records and had established reliable electronic data collection systems by the beginning of SFY 2002 (i.e., July 1, 2001). We therefore established July 1, 2001, as the start date of our data collection and determined that we would collect data on people in housing from that date through June 30, 2006, to be able to observe length of housing retention, housing stability, and the affect of receiving housing on inpatient episodes in DMH state hospitals. Housing Outcomes for HI Clients in the Metro Boston Area 3 We gathered information on all people in Metro Boston Area Office residential database who had been in HI housing run by BayCove or Vinfen during the period July 1, 2001, through June 30, 2005. About two-thirds of the people in question were in housing already at the start of that period, and about one-third moved in during the period. We matched these people to DMH Legacy and Mental Health Information System (MHIS) data to learn about hospitalizations before and after first receiving housing. We also extracted some information on client characteristics from case records maintained by BayCove and Vinfen. DMH METRO BOSTON DATA ON CLIENT RESIDENTIAL STAYS Metro Boston provided us with a list of 710 client stays of consumers who received services from Vinfen or BayCove in residential programs with HI funding during SFY 2002 through SFY 2005. Clients may have had multiple stays and their stay may have begun before SFY 2002 or continued beyond SFY 2005, but they were known to be in residence at a Vinfen or BayCove HI-supported housing program sometime during SFY 2002 through SFY 2005. For these client stays, the Metro Boston residential database was able to supply the following information: vendor code, move-in date, program name, move-out date, last name, first name, Social Security number, and DMH client ID. 2 Data cleaning and editing resulted in an unduplicated count of 628 clients who accounted for the 710 housing stays in the Metro Boston residential database. We then dropped 27 clients from the analysis because their data on entries and exits from housing were incomplete, leaving a final sample of 601 clients. Most of these clients (88 percent) had only one residential stay during the observation period. Residential stays for clients in this group could have been (1) continuous throughout the whole period, (2) in residence at the start of the period but left during the period, (3) moved in after the start of the period and are still in residence at the end, or (4) moved in after the period started and moved out before it ended. A few clients (12 percent) had two residential stays during the observation period, and one or two clients had three stays. DMH MHIS AND LEGACY DATASETS DMH records information about patient stays in DMH-funded state psychiatric hospitals and hospitals under contract to the Department for psychiatric care. DMH searched Legacy and MHIS files for inpatient hospital stay data for the 203 clients who moved into HI housing offered by Vinfen or BayCove between July 1, 2002 and June 30, 2005 (our observation period), and for another 250 clients who moved into HI housing with those providers during the previous four years (July 1, 1998, through June 30, 2002). 3 DMH data show that 38 percent (174 of the 453 2 Note that the residential stays we tracked do not include non-HI-supported housing at Vinfen or BayCove, or any housing, HI-supported or not, at other permanent supportive housing providers in the Metro Boston area. We come back to this point when we describe the length of client stays and where they went if they left the HI-supported housing provided by Vinfen or BayCove. 3 DMH Legacy and MHIS databases do not record the details of any type of hospitalization or mental health treatment delivered by non-DMH community or private hospitals, clinics, or private providers. If, in this evaluation’s Task 4, we are able to access and analyze Medicaid and MassHealth data on these other types of service that DMH clients might use, we will be able to analyze the effects of housing on a much wider variety of service use than just DMH state hospital stays. Housing Outcomes for HI Clients in the Metro Boston Area 4 clients) had received DMH hospital inpatient services from FY 1997 (up to two years before the first move-in in FY 1999) through FY 2006 (up to two years after the last move-in in FY 2005). PROVIDER DATA Vinfen and BayCove staff cooperated extensively with this project. We asked them to extract data from their electronic data files that would let us understand client demographic data, housing and service types and durations, and cost data. We met several times with provider staff to discuss the data we were interested in and to ascertain if they routinely collected that data in electronic format. We received a good deal of useful data from these providers, which provide basic demographic characteristics of DMH clients in HI-supported housing. We also used these data to verify and sometimes update the accuracy of the housing information in the Metro Boston residential database. RESULTS Vinfen and BayCove data on the people they serve provided us with some basic descriptive characteristics of the 601 clients who were tenants in their HI-supported housing projects at any time during the observation period. We learned that 31 percent were female, 63 percent were male, and gender was not known for 6 percent. 40 percent were white, 37 percent were African-American, 10 percent were Hispanic, 3 percent were Asian, 2 percent were “other race,” and race/ethnicity was not known for 8 percent. Most (70 percent) were single, never-married individuals, 3 percent were currently married, 12 percent were separated or divorced, 1 percent were widowed, and marital status was not known for 14 percent. We organize our report of results around four questions relating to the original issues of concern to DMH: 1. 2. 3. 4. How long do people stay in HI-supported housing? For those who have left HI-supported housing, are they still connected to DMH? How are Homeless Outreach Team contacts and housing placement related? Does living in HI-related housing make a difference in tenants’ need for hospitalization? HOW LONG DO PEOPLE STAY IN HI-SUPPORTED HOUSING? The hope and expectation of HI-supported housing is that the homelessness and residential instability of people with serious mental illness will be solved by receiving this place to live accompanied by the supports that help avert crises leading to housing loss. We come at this question in two ways. First we ask, for those who were in housing at any time during this period, how long were they housed? Since some people have been in HI-supported housing for 12 or 13 years while others have just moved in, this approach is “a look backward.” Second we ask, for those who entered housing during SFY 2003, 2004, and 2005, how long have they stayed? This approach is “a look forward,” since we can account for everyone who entered housing during Housing Outcomes for HI Clients in the Metro Boston Area 5 those years, we can learn about the patterns of housing retention for each new cohort. Please note that the HI housing in question is limited to projects operated by Vinfen and BayCove. It is possible that people who left and did not return to HI housing with these providers could have been in non-HI housing with the same providers, or HI or non-HI housing with other providers. We explore these possibilities in the next section. Looking Backward Table 1 shows time in housing for every person who was in HI-supported housing at any time during the observation period. The first row of the table shows the housing history of the 398 people who were already in HI-supported housing at the start of the period, July 1, 2002. The very large majority of these people (87 percent) had been in housing for more than three years. About half (49 percent) had moved in during the three years before the observation period, with another 30 percent moving in between July 1, 1996, and June 30, 1999. The remaining 22 percent moved in even earlier, with a few taking up tenancy as early as 1991. The longeststaying tenant had been in housing almost 14 years. The remaining rows of table 1 show patterns of housing retention for each annual cohort. They include people who remain in housing and those who have left. For the group of DMH clients who entered HI-supported housing in SFY 2003, for example (second row of table 1), 27 percent retained their housing for less than one year, and had not returned to HI-supported housing by June 30, 2006, the end of the observation period. Thirteen percent stayed in housing between one and two years, and 17 percent remained for two to three years. Two in five stayed in housing for three years or more. Table 1: Retention in HI Housing All Tenants Ever in Vinfen or BayCove Housing between July 1, 2002, and June 30, 2006 (N = 601) Moved into HI Number Median Percentage who stayed in HI-supported housing at Vinfen or BayCove housing of days people housed Fewer Between 365 Between 730 and 1095 days or than 365 and 729 days 1094 days (2–3 more (> 3 days (< 1 (1–2 years) years) years) year) Before 7/1/02 398 2369 3 5 6 87 Between 7/1/02 70 963 27 13 17 43 and 6/30/03 Between 7/1/03 77 746 32 17 51 and 6/30/04 Between 7/1/04 56 483 23 77 and 6/30/05 Looking Forward People who moved in after July 1, 2002 have not had a chance to stay in housing for 14 years— after all, only one or two of the people who moved into HI-supported housing that long ago are still there, and we do not know what happened to the rest. But we can use the most recent cohorts who have moved into HI housing at Vinfen or BayCove to answer the question of what proportion of each annual cohort is still in that HI housing with the same providers after a Housing Outcomes for HI Clients in the Metro Boston Area 6 specific period of time. For the 203 tenants in the SFY 2003, 2004, and 2005 move-in cohorts combined, 6 months after move-in—83 percent were still there. 12 months after move-in—72 percent were still there. 18 months after move-in—62 percent were still there, of the 185 tenants who could be assessed for 18-month retention (the others had moved in less than 18 months before the end of the observation period) 24 months after move-in—51 percent of the 168 tenants for whom we could assess 24month retention were still in Vinfen or BayCove HI-supported housing at that time. These rates of housing retention are comparable to those achieved by other permanent supportive housing programs for severely disabled formerly homeless tenants. In addition to these people who are still in HI-supported housing at Vinfen and BayCove, most of those who left this housing with these providers are still in housing of one or another variety under DMH auspices, as we see in the next section. IS DMH STILL HOUSING THE PEOPLE WHO LEFT VINFEN OR BAYCOVE’S HI-SUPPORTED HOUSING? The next question that might occur to a reader is—what happened to all the people who left the HI housing run by Vinfen and BayCove? Is DMH still taking care of them in one or another way, or are they fending for themselves? To answer this question, DMH was able to compare its ongoing client database to the list of people who had left the HI housing we tracked for this evaluation. The results of this exercise make very clear that DMH has continued to serve these clients in many ways, including further housing placements in a variety of settings and supportive services and treatment of several types. Of the 321 people who were in HI-supported housing with Vinfen or BayCove at some time during this evaluation’s observation period but were not still in that housing at the end (June 30, 2006), DMH was able to track 305 (95 percent) with confidence as of June 25, 2007. Living Situation of People Who Left HI Housing at Vinfen or BayCove Of the 305 that DMH could track, 12 have died, leaving 293 for whom DMH was able to determine living situations as of the last time any DMH contract service provider entered data on their situation: 4 4 169 (58 percent) were in some type of permanent housing. Eighty-nine are in DMHaffiliated housing with HI-funded services; 18 are in DMH-affiliated housing but DMH funds their services through non-HI resources, and 62 are in other housing (not DMHaffiliated) and receive at least one type of DMH supportive service. Housing types could Percentages in parentheses are calculated against the 293 living people in our sample who left HI housing at Vinfen and BayCove and whom DMH could locate. Housing Outcomes for HI Clients in the Metro Boston Area 7 include permanent supportive housing, and other DMH living arrangements such as staffed or supported group living and staffed apartments, and private residences). 105 (36 percent) were in DMH-affiliated transitional housing placements of one or another variety. While in that housing, 95 were receiving at least some services funded by HI, while the remaining 10 received other DMH services. 6 (2 percent) were homeless, including those on the street, in an emergency shelter, or in a DMH transitional shelter. 6 (2 percent) were in institutions, including a DMH inpatient facility (2), private inpatient facility (2), or a nursing home (2). 7 (2 percent) had moved out of the Metro Boston area. DMH Services Participation among Those Who Left Vinfen or BayCove HI Housing In addition to helping with a person’s housing situation, the Department strives to provide services a DMH client may need to proceed with recovery and succeed in retaining his or her housing. Of those same 293 clients who left Vinfen or BayCove’s HI-supported housing, 253 (86 percent) are currently eligible for DMH Continuing Care Services in the Community and 248 are receiving at least one DMH contracted community service, including: 208 (71 percent) are currently enrolled in Adult Residential Services.5 95 (32 percent) are currently enrolled in Adult Case Management services. 60 (20 percent) are currently in Community Rehabilitative Support Service. 32 (11 percent) are currently in Day Rehabilitation. 20 (7 percent) are currently in Supported Education and Employment. 4 (1 percent) are currently in a DMH hospital. Most of the 248 former HI tenants are involved with more than one DMH service, as is obvious from the percentages just reported. Only 37 percent of the 248 receive just one service, while 33 percent receive two services, 21 percent receive three services, and 8 percent receive four or more services. WHAT IS THE ROLE OF THE HOMELESS OUTREACH TEAM? DMH supports a Homeless Outreach Team in the Metro Boston area, whose job is to connect with homeless people on the streets or in shelters who either are already or are eligible to be DMH clients, and work with them to get them into DMH residential shelters or other transitional or permanent housing programs. Given the HOT’s mission, one question about its success is the degree to which it was involved in helping the people it contacts to move into HI housing. With 5 Percentages in parentheses are calculated against the 293 living people in our sample who left HI housing at Vinfen and BayCove and whom DMH could locate. Housing Outcomes for HI Clients in the Metro Boston Area 8 this question in mind, we contacted the HOT to see what types of data it keeps and whether we could use any of it for the type of analysis we had in mind. HOT keeps some records of the people it sees, but they are not available electronically. Center for Social Policy researchers working on this evaluation were able to obtain these records and to have them coded, but received only the month of contact, not the exact dates. They looked for the presence of any HOT contact and then for the month(s) in which contact occurred, for all the people (601) who were in HI-supported housing in Metro Boston during the observation period. HOT records go back many years, so even for the HI housing tenants who moved in many years ago, we were able to see whether the HOT had connected with them. We can report the following: 52 percent had had contact with HOT. 98 percent of those with a HOT contact were in touch with HOT before moving into HIsupported housing. Most the “before housing” HOT contacts occurred in the same month that people moved into HI-supported housing, suggesting a fairly strong relationship between HOT and the opportunity to move into housing. 30 percent of clients had a HOT contact after they moved into HI-supported housing, but these were not first HOT contacts. Some who left housing had contact with HOT after they moved out. These data suggest, although we cannot say definitively, that for the people HOT sees, it provides an important link to housing resources, fulfilling one of its primary purposes. HOW DOES HI-SUPPORTED HOUSING AFFECT THE LIKELIHOOD OF HOSPITALIZATION? The question of housing’s impact on service use, especially on the possibility that it may reduce the number and duration of hospitalizations, is very important. Hospitalizations disrupt the lives of DMH clients and may even cause them to lose housing and become vulnerable to a new episode of homelessness if they cannot find housing when a hospital episode ends. In addition, hospitalization is costly to DMH and the state budget. One of the most compelling rationales for DMH to develop its wide array of community-based housing has been that keeping people in housing is better for the people, better for the Department, and makes for sound fiscal policy in terms of how state appropriated funds for the Department are expended. We can definitively report that HI-supported housing completely justifies that rationale. To look at the impact of housing on hospitalization, one must compare apples and apples. It is important that the time frames of “before” and “after” housing placement be equal, and that one track everyone who has ever been in housing, not just the ones who are still there. We did this with people in the SFY 2003, 2004, and 2005 HI housing entry cohorts (N = 203) that we used to answer the question of housing retention, and added another 250 people who entered HI housing at Vinfen and BayCove during SFY 1999, 2000, 2001, and 2002 (N = 250). Thus we have a total 9 Housing Outcomes for HI Clients in the Metro Boston Area of 453 people for whom we can compare hospitalization experience before and after moving into HI-supported housing. 6 For all 453 people who first moved into HI-supported housing between July 1, 1998 and June 30, 2005, we determined the date they first moved into HI-supported housing, and then determined what dates would represent 730 days (i.e., two years) before that date and 730 days after that date. We then compared those dates to the data on hospitalization admission and discharge dates supplied by DMH from its Legacy and MHIS databases. We took only hospital days that fell within the 730-day “before” and 730-day “after” windows, even if a hospitalization had begun earlier than two years before move-in or ended more than two years after move-in. Thus the maximum number of days anyone could have had in hospital before move-in was 730, likewise the maximum after move-in was 730. A number of people had additional hospitalizations that occurred before or after this four-year window, but those hospitalizations are not included in this analysis. Table 2 shows the dramatic decline in hospital episodes among DMH clients who were placed in HI-supported housing. The proportion of clients who had a hospitalization in the two years following housing placement was only about one-fifth of the proportion who were hospitalized in the two years before housing placement; the episodes per client fell equally sharply. Table 2: Episodes of Hospitalization before and after Moving into HI-Supported Housing at Vinfen or BayCove 2-year period: Before move-in After move-in Number of episodes 198 36 (N = 453) Episodes/all clients 0.44 episode/client 0.08 episode/client Number of clients with an episode 146 28 Proportion of all clients with an episode 32% 6% Table 3 continues the story of reduced hospitalization, showing effects even more dramatically when one looks not at episodes but at days spent in the hospital. During the two years before moving into HI-supported housing, the 146 clients with hospital stays spent 46,423 days in a DMH hospital. Averaging these days over all 453 clients in housing yields an average number of hospital days per client in housing of 102. The cost of these days to DMH, calculated at an average routine daily cost of $420 a day 7 was $19.5 million over the two-year “before” period of observation. That translates to $9.75 million a year, or 42 percent of the recent annual Special Homeless Initiative appropriation of $23.1 million. In the two years after housing placement, average per-client-in-housing hospital days dropped by 93 percent, from 102 to 7, with a commensurate drop in cost per average client. 6 Two factors led us to drop 148 clients from this analysis. First, too few clients remained in housing from the cohorts that entered before FY 1999, so we knew we did not have good cohort representation. Second, DMH data on hospitalizations for the years before FY 1997 were deemed too unreliable to allow us to include in this analysis the remaining 148 clients who entered HI housing at Vinfen or BayCove before FY 1999. 7 Taking the average of routine daily costs for DMH hospitalization for seven of the years between SFY 1997 and SFY 2006 for which cost data were available; per day per FY costs ranged from $399 to $473, and averaged $420. 10 Housing Outcomes for HI Clients in the Metro Boston Area Table 3: Hospital Days and Hospital Costs before and after Moving into HI-Supported Housing In the two-year period: Before move-in After move-in Number of hospital days (N = 453) Average number of days per client 46,423 3,310 102 7 Total routine hospitalization cost to DMH for these days* $19,497,660 $1,390,200 Cost per average client for the twoyear period* $43,041 $3,069 * Cost calculation uses the average of the actual routine per day cost of hospitalization in a DMH state facility for seven fiscal years; per day per FY costs ranged from $399 to $473, and averaged $420. LESSONS LEARNED AND RECOMMENDATIONS FOR THE FUTURE The biggest, most obvious, lesson to be derived from the data just presented is that housing with supportive services matters and works! It matters a lot to clients, in that they are spared repeated cycles of housing loss, subsequent homelessness, and their related despair. They may possibly also experience less frequent and less severe cycles of recurring psychiatric symptomatology, because supportive services staff are able to observe signs of imminent decompensation and work with tenants to help them stay on an even keel. Housing also matters to DMH and the state budget, in that the Department’s per-client-inhousing savings from reduced hospitalizations, $39,972 per housed client less in the two-year period after getting housing than in the two-year period before move-in, more than makes up for any cost of keeping clients in housing. In combination with the findings of the second report of this evaluation, on the resources that DMH is able to leverage using HI funding as match, it should be very clear to policy makers that community-based permanent supportive housing more than pays for itself. These facts, coupled with the equally important outcome of ending or preventing homelessness for DMH’s very vulnerable clients, should be argument enough for continuing to expand both HI funding and permanent supportive housing development for the future. These results would not have been possible without the dedication of the agencies that have developed and now offer permanent supportive housing to homeless or high risk DMH clients. Vinfen and BayCove, two of the largest of these providers, contributed to the positive findings of this evaluation not only through their cooperation with data collection, but also through their efforts to obtain the capital and operating funds to create the housing that HI resources then support, and through their substantive services that help to keep clients housed once they are placed. The HI accomplishments detailed in this and previous evaluation reports reflect on their work. It also appears to be the case that DMH’s Homeless Outreach Teams are accomplishing one of their most important missions—to connect homeless people on the streets and in shelters to housing. HOT record keeping could be improved significantly, which would provide the data to make the case for HOT’s effectiveness a good deal stronger than it is at present. But improved record keeping could then be used to make the case for HOT expansion to be able to cover the various private hospital psychiatric wards that now often discharge DMH clients or potentially eligible people without adequate planning for where they will live when released. Housing Outcomes for HI Clients in the Metro Boston Area 11 PRACTICAL MATTERS From the beginning, DMH has assumed that the final part of this evaluation would be an assessment of the cost of physical health, mental health, and substance abuse treatment before and after HI housing placement. Medicaid/MassHealth billing records maintained by the state’s Office of Medicaid contain the data needed to make this assessment. The present report has documented the volume of savings to DMH’s budget arising from reduced inpatient mental hospital costs following housing placement, but these results tell only part of the tale. Still missing are private psychiatric hospital emergency department and inpatient costs, costs for substance abuse treatment wherever delivered, and primary care costs wherever these may be encountered. RECOMMENDATION: Conduct analyses of Medicaid/MassHealth billing records for DMH clients placed in HI-related housing, to give a broader picture of costs avoided through housing placement. For DMH to have a complete picture of how permanent supportive housing influences these broader public costs, it is essential that the evaluation follow through with its last phase— obtaining and analyzing Medicaid/MassHealth cost information for the periods before and after housing placement and reporting the results to policymakers. As we did for the evaluation report on HI-leveraged funding, we also make a strong recommendation to DMH to keep better records, and to keep those records in formats that allow a manager to retrieve data and assess performance on a regular and systematic basis. Of the data used for this report, we found that the records from Vinfen and BayCove were very good for some things but lacked some of the information we needed most (e.g., time away from housing for hospitalization or other types of inpatient treatment); the records did also contain more service-related data than we could use for this evaluation. For housing and hospitalization patterns we relied on the Metro Boston Area Office’s residential database and DMH’s Legacy and MHIS databases. Even with these databases, we had to patch together each person’s story by what amounted to a “by hand” process of making sense of conflicting or missing entry and exit dates from the different sources. Finally, the HOT data were not computerized, but consisted of many separate sheets of paper going back years, but containing only month, not day, of contact. Thus we had to hand-code them before they could be analyzed and compared to the timing of housing entry for the people in HI-supported housing. Back in 2003, when the third author approached DMH to ask about its willingness to participate in a HUD-funded study of homelessness prevention, Central Office staff were eager but also warned that “we have a lot of data, but they’re scattered all over the state and it may be a lot of work to make them tell a story.” Those staff people were right! Now that DMH’s computer resources are up to the job, it would be in the state’s and DMH’s clear interest to move quickly toward keeping better, more accessible, more useful records of the activities and outcomes that matter most to the Department. Only with good records can the Department demonstrate how well it is doing its job, and give itself the ability to know what is going well and what needs improvement.