The Emerging Crisis
of Aged Homelessness:
Could Housing Solutions Be
Funded by Avoidance of
Excess Shelter, Hospital, and
Nursing Home Costs?
Dennis Culhane, PhD, Dan Treglia, PhD
Thomas Byrne, PhD
Stephen Metraux, PhD
Randall Kuhn, PhD
Kelly Doran, MD MHS
Eileen Johns MPA, Maryanne Schretzman, DSW
Funders
New York State Health Foundation
Conrad N. Hilton Foundation
Aileen Getty Foundation
Blue Cross Blue Shield of Massachusetts Foundation
Data Providers
NYC Department of Social Services
NYS Department of Health
Center for Medicare and Medicaid Services, Mission Analytics
Los Angeles Homeless Services Authority
County of Los Angeles
California Office of Statewide Health Planning and Development
MassHealth
Boston Department of Neighborhood Development
Acknowledgements
2
Projections of the Aging Homeless Population
Understanding Healthcare Service Usage of Older Homeless Adults
Identifying Subgroups by Shelter & Healthcare Service Use
Identifying Potential Cost Offsets
Considering Stakeholders & Possible Next Steps
Agenda
for Presentation
3
Homelessness, A Birth Cohort Phenomenon
6
4
2
0
8
10
12
% o
f S
ingle
Adult M
ale
Hom
ele
ss
Popula
tion
Single Adult Male Shelter Users, United States
Sheltered Homeless
Single Adult Males
Aged 46-54
%
1990 1 in 8 in 1990
2000 1 in 5 in 2000
2010 1 in 3 in 2010
4
Forecasting Change in 65+ Homeless Population
1.0
1.5
2.0
2.5
3.0
Popula
tion G
row
th R
ela
tive to
20
17
Los Angeles Boston
2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
New York City
5
NYC Age 50+ Shelter population
forecast
0
5,000
10,000
15,000
20,000
25,000
2004
2006
2008
2010
2012
2014
2020
2022
2024
2026
2028
2030
50-54 55-59 60-64 65-69 70+
2016
2017
2018
Actual
6
Forecast
7,000
6,000
5,000
4,000
3000
2,000
1,000
0
8,000
65-69 70-74 75-79 80+
NYC Age 65+ Shelter population
forecast
2004
2006
2008
2010
2012
2014
2020
2022
2024
2026
2030
2028
2016
2017
2018
Actual
7
Forecast
Change in Shelter Population for 5-Year Birth Cohorts:
New York City, 2005 - 2030
6,000
5,000
4,000
3,000
2,000
1,000
0
1945-49 1960-64
Num
ber
of adults in
Shelte
r
1950-54 1955-59
2005 2010 2015 2020 2025 2030
8
Aging Homelessness Trends Across U.S
9
Boston
Shelter: City of Boston HMIS
Health care: MassHealth Medicaid Claims
Homeless Services Authority &
Los AngelesShelter: Los Angeles
Point-in-Time Count
Health care: LA Enterprise Linkage Project (Departments of
Public Health, Mental Health, & Health Services), CMS (through
Mission Analytics); California Office of Statewide Healthcare
Planning & Development
New York City
Shelter: NYC Department of Social ServicesHealth care: NYS Department of Health SPARCS Database,
CMS (through Mission Analytics)
Examining Shelter, Healthcare, and Nursing Home
Use & Costs of Older Homeless Adults
Data
Sources
10
Average Annual Per Person Costs by Age: New York City
$25,159 $24,455
$27,314$28,457
$5,000
$0
$10,000
$15,000
$20,000
$25,000
$30,000
55-59 60-64 65-69 70+
Nursing Home
Inpatient Care
ED Visit
Shelter
11
Nursing Home Use by Age: LA County
8
6
4
2
0
12
20
18
16
14
12
10
# o
f D
ays
in N
urs
ing
Hom
es
31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75
Age
Projecting Total Costs through 2030: New York City
Costs
Per Year,
mill
ions o
f$
$500
$450
$400
$350
$300
$250
$200
$150
$100
$50
$02004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
Shelter Healthcare
13
Cluster Analysis: A tool for grouping observations based on
similarities and dissimilarities
Clusters were created based on a small set of variables, and
validity was assessed through other variables of service use
and medical acuity
Segmenting into Subgroups
to Assess Potential Housing
& Service Needs
14
Shelter Use
Low Moderate Very High
Low
Moderate
High
High
Shelter Days
2009 - 2015
Gagne Inpatient
Comorbidity Hospital Days
Index 2011 - 2015Cluster Description
1 Moderate shelter use, Moderate medical need 11,354 (84.6%) 270 2.2 16
2 High shelter use, Moderate medical need 1,536 (11.4%) 1,191 3.1 20
3 Very high shelter use, Moderate medical need 193 (1.4%) 2,201 1.9 14
4 Low shelter use, High medical need 344 (2.6%) 56 32.5 253
Cluster Share
Su
bg
rou
p A
naly
sis
Resu
lts
Me
dic
alN
ee
d
Cluster 4
2.6%
Cluster 1
84.6%
Cluster 2
11.4%
Cluster 3
1.4%
15
Shelter
Days
Inpatient
DaysED
Visits
Nursing
Home
Days
Shelter
Cost
Health
Services
Cost
Total
Services
Cost
Cluster 1 44 3 1 9 $5,167 $13,369 $18,536
Cluster 2 196 4 2 6 $23,018 $15,870 $38,888
Cluster 3 329 3 1 3 $38,638 $10,281 $48,919
Cluster 4 9 51 10 32 $1,075 $175,437 $176,494
4
1 2 3
Shelter Use
Me
dic
alN
ee
d
Su
bg
rou
ps: A
nn
ualized
Sh
elt
er
& H
ea
lth
ca
reU
se
16
Envisioning a
Continuum of
Potential Interventions
17
Expect homelessness to self-resolve for one-third of this cluster, as
people move in with friends, family, partners, etc.
For the remaining 2/3, we assume an equal division of:
Rapid Rehousing: relocation and case management services and
time-limited rental assistance
Shallow rental subsidies: for those needing ongoing modest rental
assistance for shared living arrangements and minimal financial and
social service support
Rental vouchers, like those available through HUD’s Section 202
program, in addition to light case management, and likely to be living
alone
19
Subgroup 1:
Progressive Engagement
4
1 2 3
Shelter Use
Me
dic
alN
ee
d
Long-term housing + supportive services for chronically homeless
populations
All three groups may need advanced case management and home
care services that allow for aging in place
Subgroup 4 are likely candidates for palliative care and additional
nursing home transition services
Subgroups 2, 3, and 4:
Permanent Supportive
Housing
4
1 2 3
Shelter Use
19M
ed
ica
lN
ee
d
Es
tim
ati
ng
Co
sts
fo
r E
ach
Inte
rven
tio
n
Intervention
Annual Housing Cost
AnnualServiceCost
Total Annual Cost
Cluster 1 Subsidy + Services $4,795 $1,650 $6,444
Cluster 2 PSH $15,468 $11,500 $26,968
Cluster 3 PSH $15,468 $11,500 $26,968
Cluster 4 PSH + Additional
Supports
$15,468 $23,000 $38,468
4
1 2 3
Shelter Use
Me
dic
alN
ee
d
20
22
Estimating Service Cost Reductions
1.Aubry T, Goering P, Veldhuizen S, et al. A Multiple-City RCT of Housing First With Assertive Community Treatment for Homeless Cana-dians With Serious Mental Illness. Psychiatr Serv. 2016;67(3):275-281.
2.Basu A, Kee R, Buchanan D, Sadowski LS. Comparative cost analysis of housing and case management program for chronically ill homeless adults compared to usual care. Health Serv Res. 2012;47(1 Pt 2):523-543.
3.Rosenheck R, Kasprow W, Frisman L, et al. Cost-effectiveness of Supported Housing for Homeless Persons With Mental Illness. Arch Gen Psychiatry. 2003;60(9):940.
4.Stergiopoulos V, Hwang SW, Gozdzik A, et al. Effect of scattered-site housing using rent supplements and intensive casemanagement on housing stability among homeless adults with mental illness: a randomized trial. JAMA. 2015;313(9):905-915.
5.Byrne T, Smart G. Estimating Cost Reductions Associated with the Community Support Program for People Experiencing Chronic Homelessness. Boston, MA; 2017.
6.Culhane DP, Metraux S, Hadley T. Public Service Reductions Associated with Placement of Homeless Persons with Severe Mental Illness in Supportive Housing. Hous Policy Debate. 2002;13(1):107-163.
7. Gilmer T, Manning W, Ettner S. A Cost Analysis of San Diego County’s REACH Program for Homeless Persons. Psychiatr Serv. 2009.
8.Larimer ME, Malone DK, Garner MD, et al. Health care and public service use and costs before and after provision of housing for chron-ically homeless persons with severe alcohol problems. JAMA. 2009;301(13):1349-1357.9.Martinez TE, Burt MR. Impact of permanent supportive housing on the use of acute care health services by homeless adults.Psychiatr Serv. 2006;57(7):992-999.
10.Seligson A, Levanon S, Lim T, et al. New York/New York III Supportive Housing Evaluation: Interm Utilization and Cost Analysis. New York; 2013.
11.Srebnik D, Connor T, Sylla L. A pilot study of the impact of housing first-supported housing for intensive users of medical hospitaliza-tion and sobering services. Am J Public Health. 2013;103(2):316-321.
12.Hunter SB, Harvey M, Briscombe B, Cefalu M. Evaluation of Housing for Health Permanent Supportive Housing Program. Santa Monica, CA; 2017.
13.Mares AS, Rosenheck RA. Twelve-Month Client Outcomes and Service Use in a Multisite Project for Chronically Homelessness Adults.
14.Thomas LM, Shears JK, Pate MC, Priester MA. Moore Place Permanent Supportive Housing Evaluation Study Final Report. Char-lotte, NC
15. Wright BJ, Vartanian KB, Li H-F, Royal N, Matson JK. Formerly Homeless People Had Lower Overall Health Care Expenditures AfterMoving Into Supportive Housing. Health Aff. 2016;35(1):20-27.
Service Cost
Reduction Scenarios
Scenario 1
More conservative
Based on a pooled average of the percentage change in health care
costs associated with housing placement that were observed in all
studies that were reviewed. Studies were weighted so those with
stronger methodological rigor had larger weights and greater impact
on the pooled average.
Scenario 2
Less conservative
Based on a pooled average of the percentage change in health
care costs associated with housing placement that were observed
in all studies that identified a significant reduction in health care
costs.
22
A Range of
Potential Service Cost
Reductions
23
Cost Category
Scenario 1
(More conservative)
Scenario 2
(Less conservative)
Inpatient medical -18% -33%
Emergency Department -6% -45%
Outpatient medical -6% -45%
Outpatient behavioral health 48% -29%
Inpatient behavioral health -35% -56%
Nursing home -42% -90%
Shelter -71% -71%
Cost Reduction Possibilities by Age Group:
LA County Average per Person Per Year
$5,498
$8,869
$5,951
$9,834
$6,570
$10,668
$6,978$6,969
$11,346
$4,000
$2,000
$-
$6,000
$8,000
$10,000
$12,000
t
Age 55-59
Age 60-64
Age 65-69
Age 70+
More Conservative Less Conservative
Cost Reduction Scenarios Housing Intervention Cos
24
Cost Reduction Possibilities in NYC Average
Per Person Per Year
$9,171
$13,215
$11,033
$0
$8,000
$6,000
$4,000
$2,000
$10,000
$12,000
$14,000
More Conservative Less Conservative
Service Cost Reductions Housing Intervention Cost
25
Cost Reduction Possibilities in Boston Average
Per Person Per Year
$4,946
$9,073 $9,052$10,000
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
More Conservative Less Conservative
Service Cost Reductions Housing Intervention Cost
26
27
* Boston service costs and cost reductions exclude Medicare-reimbursed services. Aforthcoming analysis estimating Medicare costs suggests that an intervention would bebreak-even or provide net savings
Annualized Average Projected Costs & Potential Cost Reductions
(in millions of $)
Net Offsets (Service Cost
Service Costs
without an InterventionIntervention Costs
Average Service Cost Reductions
Reductions -Intervention Costs)
Return Per Dollar Spent
New York City $408 $157 $177 $20 1.13
Boston* $67 $39 $30 ($9) 0.77
LA County $621 $241 $274 $33 1.14
Yes
Could
Housing Solutions be Funded by
Resultant Service Cost Reductions?
28
National Projections (with cautions)
0
250,000
200,000
150,000
100,000
50,000
2017 2018 2019 2020 2021 2022 2025 2026 2027 2028 2029 20302023 2024
55-64 65+
29
U.S. HUD & VA
U.S. DHHS – CMS
State Medicaid Regulatory Agencies
Medicaid Managed Care Organizations
Hospitals & nursing homes
Homeless Service Providers (CoC’s)
Housing Authorities
Local Area Agencies on Aging
Key Stakeholders
30
• How to advance fund the housing “investment”?
• MCOs as rapid rehousing funder under a critical time intervention model?
• Start now targeting hospital and ER discharges and nursing home diversion?
• Ramp up over time, starting with 65+ or 62+ to gain momentum and develop policies and procedures?
• Federal challenge grant program to states for pilots?
• Local/state pay for shallow subsidies as alternative to shelter, and sunsetting over time?
• Hospitals as key local leaders and conveners? Dissuade from “medical respite” push?
Policy
Considerations
31
