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:
ƒ
The cumulative number of persons housed and receiving supportive services paid for by
HI;
ƒ
The tenure of these persons in housing;
ƒ
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
ƒ
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
ƒ
31 percent were female, 63 percent were male, and gender was not known for 6 percent.
ƒ
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.
ƒ
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,
ƒ
6 months after move-in—83 percent were still there.
ƒ
12 months after move-in—72 percent were still there.
ƒ
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)
ƒ
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
ƒ
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).
ƒ
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.
ƒ
6 (2 percent) were homeless, including those on the street, in an emergency shelter, or in
a DMH transitional shelter.
ƒ
6 (2 percent) were in institutions, including a DMH inpatient facility (2), private inpatient
facility (2), or a nursing home (2).
ƒ
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:
ƒ
208 (71 percent) are currently enrolled in Adult Residential Services.5
ƒ
95 (32 percent) are currently enrolled in Adult Case Management services.
ƒ
60 (20 percent) are currently in Community Rehabilitative Support Service.
ƒ
32 (11 percent) are currently in Day Rehabilitation.
ƒ
20 (7 percent) are currently in Supported Education and Employment.
ƒ
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:
ƒ
52 percent had had contact with HOT.
ƒ
98 percent of those with a HOT contact were in touch with HOT before moving into HIsupported housing.
ƒ
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.
ƒ
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.