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Homeless and Housing Meeting Recap for December 3, 2019

(MSCC) John Mudd, January 3, 2020

TO: Committee Members and General Public

FROM: Matt Green, Councilman Corey Johnson’s Office; John Mudd and Sharon Jasprizza, Midtown South Community Council

SUBJECT: Homeless and Housing Committee Meeting recap for Tuesday, December 3, 2019 at 9:30am, plus upcoming meeting reminder and announcements 

NOTE: New meeting location, below!

PURPOSE: To develop partnerships and resources to identify problems and find solutions for our homeless and housing crisis

We covered a wide range of topics during our recent December 3, 2019 meeting. Boston’s Barbara McInnes House medical respite bed visit was discussed; voucher programs dominated the meeting.

If any content below is mischaracterized or needs more clarity please let us know. And don’t forget to check out the announcements from our partners at the end of this recap!

CHAIR (December 3, 2019 meeting):Matt Green, Corey Johnson’s Office; Sharon Jasprizza MSCC

POLICY COMMITTEE’S REPORT FOR DECEMBER 3, 2019

The prior 8:30am Policy Meeting’s hour was spent briefly discussing the third draft of our Non-Medical Respite Bed Policy Recommendations (see the latest version Addendum F, pg. 23). The primary subject was medical respite beds, the committee’s visit to Boston’s Barbara McInnes House facility (see details Addendum C, Field Visit to Boston’s Medical Respite, pg. 13), and plans to encourage the development of medical respite beds in NYC. 

Daniel Pichinson, Executive Director, Ryan’s Chelsea Health Center, summarized the earlier 8:30 Policy Meeting as follows: 

It’s been identified that many housing insecure patients are likely to return to the hospital soon thereafter they are discharged without an appropriate place to recover. Mt. Sinai’s Dr. Andy Coyle, being fully aware of this problem, is partnering with, and renting beds from Communilife so people have time to recover. Health First, United, Metro, and others are recognizing that housing people in the emergency room is not an appropriate use of Medicare dollars and are also renting from Comunilife to save costs. Healthfirst says that 28% of people suffering homelessness who received emergency care return within 30 days because they have no appropriate place to recover. The approach to medical respite is piecemeal; we need a coordinated effort. Recognizing that there is not a coherent citywide approach to this problem, the committee is working towards policy recommendation and ways to encourage the city to fund a pilot program.

The committee drafted a four-step advocacy plan (see Addendum D: Medical Respite Bed Advocacy Plan, pg. 19).

SPEAKER(S) (December 3, 2019 meeting):DHS Leilani introduced Erin Drinkwater, Deputy Commissioner of Mental and Legislative Affairs, Department of Social Services, who presented an overview of HRA’s voucher, history, policies, and more:

VOUCHERS

The voucher programs were developed to provide assistance and prevent homelessness in a runaway rental market. There is no doubt that many of our elderly, medium, and low- to no-income earners are excluded from stable housing opportunities. There is no doubt that certain policies, or the lack thereof, has added to our social crisis. Erin Drinkwater speaks to this, and their new progressive, streamlined choices to mitigate past and current problems.

Advantage History: The previous City and State Advantage Voucher program ended in 2011. The result was a 115% rise within the shelter population. When the Advantage Program was eliminated, it destroyed trust with the participating landlords, because it ended their income and left them seeking evictions through the courts. 

City and State FHEPS: The Mayor has been working to reestablish the rental assistance program. The seven different programs (with seven different policies for seven different populations) were confusing for provider, landlords, and clients. To make things more efficient, HRA streamlined and consolidated voucher programs in 2018, to the City and State FHEPS. All other voucher programs should/will be rolled over into the FHEPS program. Those who have become ineligible are likely due to their increase in income. 

City FHEPS can be renewed every five years on a case-by-case basis. Funds for these programs are there. Advocates are urging an increase in rental payments, but doing so renders the state program useless. The City is keeping the levels to prevent the landlords from preferring City over State programs. 

So if we want increases we must do it on a state and city level.

Consolidation of the housing vouchers went through the capital rule making process and had a public hearing for anyone wanting to provide information to help craft a better program.

CityFHEPS is the broad program that began in October 2019. Funds are there via tax levy. State FHEPS more narrowly focused to serve families with children.

Measurements of progress: Since the DeBlasio administration, 120,000 individuals have been moved out of or avoided the shelters using a variety of assistance such as the 421A, Homeless Set aside, Federal funded Home TBRA (finite program), FHEPS Vouchers, and others.

Tentatively Housed

CityFHEPS is limited for tentatively housed individuals who live within the community. Tenants need to meet the following criteria:

  • Income eligibility/low income
  • Be on a caseload
  • Rent stabilize or rent control
  • Veteran
  • APS, Adult Protection Services

The city is committed to tenant preservation. Those people who fall outside the above criteria have other means of protection such as:

  • Office of Civil Justice
  • Anti-Eviction and Harassment services, currently in some zip codes and will be completely rolled out by 2022
  • The Right to Council
  • One Shot Deal, that will cover rent or utility bills 
  • SOTA (1 year) program assesses the ability of the client to cover rent in the future

HomeBase can help mediate for a tentatively housed person.

Clients in Shelters

The goal is when someone comes seeking shelter through PATH for families with children, 30th Men’s and adult families, Franklin for Women…DHS wants to ensure that the person is taking advantage of all options to divert them away from the shelter systems, through the Homeless prevention Administration and Homeless diversion unit operating out of PATH. The eligibility runs as high as 40% of the families seeking shelter.

Information Sharing

DHS and HRA share a lot of information. The case file is built during the earlier intake process for housing readiness. DHS uses a sharing information data system called CARES to track and record people’s conditions and welfare. 

Erin Drinkwater roughly describes the people who are suffering homelessness:

  • 30% working
  • 30% suffering mental health problems (including self reported conditions of anxiety, followed by depression)
  • 40% evicted and doubling

The Single Intake Process:

  • Intake shelter (30th Street, Franklin)
  • Assigned to assessment shelter for (bio, psych, and social) to determine what caused a person’s predicament, and review job and housing readiness
  • Placed according to assessed conditions in an employment, program, substance abuse, mental health shelter
    • Individual has obligations to meet conditions for their stay (i.e., if a person is in an employment shelter, they are actively pursuing employment)

The current administration is looking to simplify and progress the program and put shopping letters into the hands of people, not to struggle through bureaucratic processes. 

Shopping Letter

DHS provides shopping letters for people seeking new housing, which details the Mayor’s Universal Access program. They also provide additional information about legal services for tenants facing eviction in housing court and what to look for when it comes to source of income discrimination by landlords.

Discrimination is prevalent; its being monitored, and DHS is working on ways to combat it.

There are 100 families who show up to a shelter for assistance every night. Erin tells us that HPD has a record of 70,000 rental units under $800, but she questions how many are really available. 

Besides a lack of affordable housing, a runaway rental market with plenty of abuses within (discrimination, deregulation, mini hotel operations), and an unwillingness or lack of incentive for private (and arguably public) to build affordable housing, our crisis screams for supportive service, from medical to social and legal.

NY/NY Agreements

NY1, NY11, NY111 are the City and State agreements promising to build thousands of units with supportive services to serve people who are mentally ill or have a substance abuse problem.

Prior to the Agreement, the New York State Office of Mental Health (OMH) had never funded the construction of permanent housing for mentally ill people, nor paid for on-site services to keep mentally ill people in permanent housing. Allocating capital money to build housing reversed years of OMH policy and signaled a historic change in the agency’s mission by acknowledging that the provision of stable, affordable housing was an integral part of mental health treatment. —The Network, Supportive Housing Network of New York

The Network, Supportive Housing Network of New York provided the following information about the NY/NY agreements and has more to offer on their website:

The 1990 New York/New York Agreement to House Homeless Mentally Ill Individuals was a historic joint effort by the State and City that created 3,615 units of supportive housing and licensed permanent and transitional housing for homeless mentally ill people in New York City. —NY1

In 1999, Mayor Rudy Giuliani and Governor George Pataki agreed to create 1,500 more units for mentally ill homeless within five years. —NY11

In November 2005, Mayor Michael Bloomberg and Governor George Pataki agreed to create “9,000 units of supportive housing for a variety of disabled homeless people in New York City over ten years. —NY111

Did the administrations meet their goals?

More is being added to the allotment of supportive housing—Erin tells us that in 2015 it was decided to bring 15,000 units in 15 years to house 2010E Supportive Housing applicants (people who are severely mentally ill). 

The eligibility has changed over time to include HIV patients, and youths who are aging out of the other shelters. Some supportive housing lite (nonprofit leases, and manages a site with basic services) has been added.

DHS is realistic about the housing market: 

  • SOTA is a social tool to solve a market problem (we need to increase available housing)
  • Trickle down housing doesn’t work
  • Housing stock has been lost
  • Supportive housing is the best solution

Other contributions to the increase of homelessness:

  • During the implementation of the NYC 1515, the supportive housing initiative of November 2015, much of the limited housing was lost (need more details)
  • Loss of SROs, single room occupancy apartment buildings
  • Institutionalization: People discharged from prison and new bail rules led to a demand for housing

A recurring conversation throughout the different administrations has been about the housing shortages.

Natural disasters and domestic violence are not reflected in the DHS’s daily shelter numbers

Comments / Questions:

Charisma pointed out doubling up (having families stay with other family members) may be reducing the shelter statistics, but does not solve the problem. Charisma’s point, along with many other conversations, goes back to housing supply. 

Marni asked about a site nearby the Elizabeth Street Gardens, where the city could build affordable housing: Why are they not doing it?

Phillip (committee member) enrolled in CityFHEPS, from the LINKS program, in 2015, and points out that the media and system puts the onus on the client rather than developers and landlords, and that the landlord/developer should have the responsibility of creating affordable housing and accountability for their unlawful evictions.

Andrew Bonfrancesco, Housing Works, voiced concerns over discriminatory practices around voucher use, enforcing maintenance, repairs, quality conditions, and code compliance.

Vicky Hines brought up the housing specialist employee turnover, which hampers efficiency and client services. She felt that the voucher programs and available housing are constantly changing.

Erik Bottcher, Councilman Speaker Corey Johnson’s office, speaks to the bureaucracy complicating a person’s chance to be housed about six months ago. Erik suggested having a conversation with the person to troubleshoot and find where the breakdown occurred. 

Erin, in defense affirmed that the voucher policies are more efficient, and agreed housing availability is a problem.

MEDICAL RESPITE BEDS

Homeless and Housing Committees’s representatives traveled to Boston’s Barbara McInnes House medical respite bed on Thursday October 24, 2019. The team included: MSCC’s John Mudd and Sharon Jasprizza; BronxWorks’ Cassie Dessalines, Mariam Alami, Martha Zabetta, Miliano, Sarah Zammiello, Juan Rivera; Reggie Miller, NYDIS; Ryan’s Chelsea Health clinic’s Sharmistha Mohapatra and Sara Samson.

Cassie organized the October 24, 2019 trip to Boston’s Barbara McInnes House medical respite center to meet David Munson and his department heads to give us an overview of their facility. The goals were to understand the center’s: 

  • Policies
  • Programs
  • Goals/Mission
  • Operation
  • Budgeting
  • Proof of Savings through Services
  • Funding
  • Efficiency
  • Benefits (social, individual, health and human services)
    • Increase in safe discharge plans
    • Decrease Against Medical Advise (AMA)
    • Decrease in length of hospital stay and recidivism
    • How are the dependent drug users supported
    • Structures to connect people with stable housing

Summary: We were looking for any metrics that prove the center’s efficiencies and net worth (see Addendum C: Field Visit to Boston’s Medical Respite, pg. 13).

The committee is meeting their outlined goals, still collecting data, and formulating a process to encourage medical respite bed development. 

Erin Drinkwater tells us that the DHS’s General Welfare Committee held a hearing in September of 2019 on medical respites; DHS provided information regarding institutional referrals and process for hospital discharges. She suggests that we look at the testimony and transcripts of that hearing. 

The DHS with the Medical Director’s office are having ongoing conversations to find the nexus in which to operate among DHS, hospitals, and providers.

DHS is looking for ways to:

  • Reduce cyclical returns to emergency rooms
  • Transition people to medically appropriate shelters when needed
  • Source stable housing for people after discharge
  • Improve communication between the agency and the hospitals about people’s health status and expected discharge dates for timely transition to housing options

Phillip, of Care for the Homeless, commented that there is an interest on a national level, but NYC is lagging on medical respite beds. 

HOSPITAL AND RESPITE CARE

During November’s meeting, Cassie discussed BronxWorks’ staff being embedded in the hospital emergency room (good), and to a much lesser degree during a patient’s respite period (not so good). Embedded social services during the respite period would be advantageous. 

Comunilife’s Beverly Raudales spoke about having two respite beds for recovering patients (not medically step-down, but medically discharged). Comunilife works to fulfill care obligations and beyond by securing stable housing. Comunilife is interested in establishing relationships with other homeless services, particularly Urban Pathways. 

Pathways from recovery to stable housing are advantageous and somewhat less complicated than other pipelines, as it eliminates street outreach.

The above Hospital and Respite Care summary was carried over from November as it relates to the Medical Respite Advocacy.

NON-MEDICAL RESPITE BED

NYDIS/ESN: The merging of NYDIS and ESN was detailed in the August recap (see MSCC’s web link). NYDIS/ESN is a network of (mostly) congregations, which provide overnight stays for people who are homeless. There is a lack of rules and policy coherence among the respite beds, clients, volunteers, and homeless service providers.

Drafting Policy Recommendations:Cassie Dessalines’ (BronxWorks) and Reggie Miller’s (NYDIS/ESN) are readying a third draft for discussion (see Addendum F: Non Medical Respite Bed Policy Recommendations, pg. 23). The recommendations attempt to balance volunteer training, needs and comfort, along with client needs. 

MTA ENFORCEMENT INITIATIVE

In June, the City announced a new “diversion pilot” policy. Somethingto be discussed at a future meeting.

INCOME SAVINGS PROPOSAL (ISP)

DHS’s proposal to mandate (generally) 30% of the shelter residents’ earnings to be put into a savings account effective date is December 15th. The proposal was briefly discussed and is tabled for February’s meeting agenda. For additional information on this proposed new rule please see: NYC Rules .

WORKSHOPS

Current workshop updates: An added workshop “Navigating the Shelter System” is being discussed.

PUBLIC BATHROOM

No updates from the public bathrooms development and planning group.

PUBLIC CONCERNS / POLICE AND COMMUNITY

Anthony Mahepath is MTS Precinct’s new NYPD Homeless outreach contact. There were no public police concerns.

ACTIONABLE LIST

The following are possible actions to consider from this meeting’s discussion:

  • Erik suggests having a conversation between the person who was hampered by bureaucratic systems and DHS/HRA to troubleshoot and find where the breakdown occurred. Others with similar problems could be invited too (SUS’s client).
  • Erin suggests watching for legislation and budgeting (that may not cover enough programs/assistance) to come from Albany: Liz Kruger’s Housing Stability bill, supporting increases of City and State voucher participation, and assistance for undocumented citizens (Federal provides only emergency assistance)

ANNOUNCEMENTS

  • Port Authority Tree planting: There are nine trees placed with guard rails
  • Laundry For Kids – Update: raised close to $4,546 and served 293 kids
  • Please support our GoFundMe campaigns: Laundry for Kids and Street Sheets

ADDENDUM A: POLICY COMMITTEE’S RECAP 11.5.19
(Sub-committee of Homeless and Housing Committee) 

November 5, 2019 Policy Meeting Recap

Location: Urban Pathways, 575 8th Avenue, 16 floor (between 38th and 39th Street)

Date: Tuesday, December 3, 2019

Time: 8:30am-9:30am

MEMBERS PRESENT

John Mudd, Sharon Jasprizza, MSCC; Dan Pichinson, Chelsea Ryan Clinic; Andrew Bonfrancesco, Housing Works; Reggie Miller, NYDIS; Vicky Hines; Patricia Miles; 

COMMITTEE’S PURPOSE

Review policies and their oversight, determine actions, suggest and lobby for change!

TOPICS

The 8:30am Policy Meeting’s hour was spent briefly discussing the second draft of our Non-Medical Respite Bed Policy Recommendations (see the latest version Addendum E). The primary subject was medical respite beds. 

RECAP

The committee discussed whether the goals for Boston’s McInnes House visit were accomplished (see outline of goals under Medical Respite Bed of this document). It was concluded that we went beyond our stated goals: We connected with willing partners, the principal operators of Boston’s Barbara McInnes House, to support our efforts to develop medical respite beds.

Boston’s medical assistance program pays for 60 million dollars to fund both Barbara McInnes medical respite facility (18 mil) and Stacey Krickpatrick (42 mil), a long-term or terminal care and housing facility with wrap around or supportive services. NYC currently would not cover the cost for such facilities through Medicaid.

Daniel’s questions were the drivers of our morning conversation:

  • Do we encourage medical respite bed funding through the city budget? 
  • Ask the city to fund a pilot project with minimum amount of beds to study the financial and clinical outcomes?
  • Or do we try to have the city encourage and support the loose network of providers that we are building to develop similar operations?
  • And do we want to publicize the need for operations such as the Barbara McInnes house?

The committee thought it prudent to pursue all avenues of advocacy, and roughly shaped a four-step plan to encourage medical respite bed development (see Addendum H Medical Respite Bed Advocacy Plan).

Daniel Pichinson noted that, Medicaid is funded through state and federal dollars. The State has requested 5 billion dollars, out of 1.5 billion set aside, to develop social issues that impact medical services. Hospitals may well be cash flush for projects of our magnitude.

FURTHER PLANNING

  • Adding policies concerning chronicity to our task list
  • Andrew: psychosocial and psychiatric evaluation policies in order to enter respite sites *Add-on
  • Review Voucher policies and oversight

ADDENDUM B: BOSTON MASSACHUSETTS MEDICAL RESPITE BED

MASSACHUSETTS / Barbara McInnis House 

Agency: Boston Health Care for the Homeless Program
Address: Jean Yawkey Place, 780 Albany Street, Boston, MA 02118 Contact: Sarah Ciambrone, Executive Director, Barbara McInnis House Phone: (857) 654-1701
E-mail: sciambrone@bhchp.org / Website: www.bhchp.org 

Description / Established 1993

Since 1988, medical respite care has been an essential component of the continuum of healthcare services provided by the Boston Health Care for the Homeless Program (BHCHP). Originating as shelter-based medical beds, medical respite care for men and women is now provided in one freestanding facility, the 104-bed Barbara McInnis House which is housed in the top three floors of Jean Yawkey Place on Albany Street in Boston and located across the street from Boston Medical Center. 

Jean Yawkey Place is home not only to the medical respite program but also the dental program, a busy pharmacy and ambulatory clinic, and administration for Boston Health Care for the Homeless Program. 

The McInnis House provides care to men and to women, and provides comprehensive medical, nursing, behavioral, dental, and case management services in an environment sensitive to the needs of homeless adults. 

The McInnis House offers three meals per day that are served in the dining room. Patients recuperate in private, semi-private or two to six bedrooms. The program admits patients 24 hours per day, seven days a week from hospitals, shelters, emergency departments, outpatient clinics, and directly from the street by referral from the BHCHP Street Team. 

Operating agency: Boston Health Care for the Homeless Program (HCH) 

Facility type: Stand-alone  / Number of respite beds: 104

Hours of operation: Admissions office – Monday thru Friday, 8am-4:30pm Average length of stay: approx. 12 days 

Admission Criteria 

• Primary medical problem 

• Psychiatrically stable 

• Independent in Activities of Daily Living 

• In need of short-term recuperative care 

• If on methadone, must be enrolled in methadone maintenance program 

• Disclosure of known communicable disease, including TB, VRE and MRSA 

ADDENDUM C: field visit to Boston Medical Respite

Notes by Ryan Chelsea Center’s Sharmistha Mahapatra, Population Health Manager, and Sara Sansone, Chronic Care Manager

We were welcomed by David Munson, Medical Director of Respite Programs at Boston Health Care for the Homeless. He is also the Chair of the Steering Committee of the Respite Care Providers Network through the National Health Care for the Homeless Council. We also met with the Deputy Chief Financial Officer, Director of Operations and Director of Nursing at Barbara McInnis House. The entire travel team discussed a number of issues with David, some highlights below.

Sites Visited

  • Large, main site: The Barbara McInnis House
  • 104-bed medical model, acute care oriented, short-stay to stabilize medical condition, and little case management (does not resolve or attempt to resolve housing issues)
  • Satellite, step-down site: The Stacy Kirkpatrick House 
  • More typical of a common respite, more likely to be a model NYC would use
  • 20-bed nursing & operational staff run, transition medically frail homeless patients from low-risk care to long-term housing

Barbara McInnis House

  • Respite first started 30 years ago within a shelter, moved from what is now Stacy Kirkpatrick House. Current building (formerly pathology site, morgue) given to Boston HCH by the city for $1 (one dollar)
  • Capital funding used for major renovations
  • Primary care FQHC on the first floor
  • Also houses a SPOT (Supportive Place for Observation and Treatment) monitoring room for 8-10 individuals to be monitored while actively under the influence of a substance at high risk of overdose. This is not a safe injection site, however
  • Respite housed on 2nd – 4th floors
  • 2nd floor is a group area (cafeteria, laundry, activity room, large recreation area, outdoor space for smoking, some offices)
  • 3rd and 4th floors appearing to be more likely an inpatient hospital
  • $16-18 million annual budget for the respite program
  • Approximately 2500 annual admissions (1200 or 1800* unique patients) 
  • 104 beds on 2 floors; most rooms 4-6 beds with TVs and headphones attached
  • 2 negative pressure rooms (for airborne isolation, but mainly used as isolation rooms for psychiatric separation)
  • Pharmacy on-site

Staffing

  • 24/7 nursing on-site
  • Daily visit with primary care + 3 nursing visits for each patient
  • 8 teams managing 13 patients
  • RN (daytime, 1 RN/team; nighttime 1 RN/2 team), 
    • 1 case manager/2 teams
    • 2 medical assistants for every floor (52 beds)
    • 3.6 FTE social workers who focus on crisis intervention and milieu management
    • 0.7 FTE psychiatrist
    • Approximately 175 staff including per diem
    • Trauma-informed training for all staff, including contracted security agency
    • AmeriCorps members
    • Challenges for staff include:
      • Embracing harm reduction, especially allowing active drug use
      • Safety, particularly outside the building rather than inside the respite
      • Managing expectations that these are not typical patients
    • Trauma specialist rotates for staff/team self-care

Admissions and Patients Demographics

  • Criteria:
    • “Too sick for shelter, but not hospital”
    • “Imagine needing to discharge someone home with VNS, only they have no home to go to”
    • Includes activity-of-daily-living independence (can wash, bathe, transfer themselves)
    • Admissions can include from colonoscopy prep to full-on cancer care and in between (e.g. hospice care, exacerbation of chronic respiratory disease, detox as secondary reason, DM/HTN or flu, surgical pre- and post-op)
  • Nursing oversees admissions
    • Respite staff Nurse Hospital Liaison embedded at hospitals constantly has to case review referrals for appropriateness because criteria is very particular
    • Liaisons are credentialed by hospitals
    • There is a referrals sheet with criteria
    • 10% daily turnover, 10-11 beds opened/day
    • 45% admissions from hospitals; 40% from outpatient (1st floor FQHC, 30-shelter based clinics, or street team); remaining from jails, detox, nursing homes. No self-referrals
    • Contract with Mass General for funding some bed-days for guaranteed access
    • On admission to program, patients have ‘benefit touch’ to enroll in insurance, etc.
    • More men than women, beds separated by sex/gender; transgendered assigned by self-identified gender
    • Approximately 80% of the population are active tobacco smokers
    • Approximately 80% of the population are active substance users (managing/treating withdrawal is secondary effort)
    • Barriers to admission can include history of sex offenses
    • Harm reduction model prevails
    • Orientation offered 2x/week for 1 hour, and run by Operations Director (required only once, so not done if patient is readmitted to the program)
    • No violence, confrontation, or racial remarks with other patients or staff is permitted 
    • Patients can’t come and go or bring in outside food
    • Escort or transportation provided to appointments (2 vans owned by respite)
    • Visiting hours allowed
    • Smoking limited to specific times and location
    • Option to attend groups run by SW or activities from external organizations
    • 2-week average length-of-stay (LOS); no mandatory end
    • Code Green ‘behavioral health response’ happens about 1/month; orientation and huddles have greatly mitigated this
    • 1/4 discharges are unplanned 
      • Some due to administrative reasons, patients leaving to get their benefits checks, substance users
      • Behavioral disturbance will be discharged but can come back on review of case 
    • Discharges planned by case managers and overseen by nursing to:
      • Street (can be followed by Street Team), shelter (most common), rest home, detox or sober homes, skilled nursing site, permanent housing support (rare and only if patients already in search process through the City)

Outcomes Data 

  • Not able to track all desired data due to disparate strength of relationship with 5 referring hospitals and lack of claims data
  • Boston Mass General (BMC) data supports that Medicaid in-patients are replaced with commercial/private pay, increasing hospital revenue by millions of dollars
  • Internal QI: Falls / medication errors / emergency events
  • External: 30 day readmit rates w/one hospital (BMC), 12-question patient satisfaction questionnaire, referral data
  • Hospital referrals average LOS: 16 days
  • Outpatients referrals average LOS: 12 days
  • Wish list for reports: Diagnoses, Disposition after discharge, Demographics
  • LOS meetings held every week; longer stays considered for step-down

Billing

  • Essential take away that this is mainly funded through provider billing—RARE for a respite
  • Mainly dealing with one ACO, greatly simplifies agreements, contracts and payment, as compared to our NYC situation
  • Boston HCH: $60 million annual budget, Barbara McInnis $18 million (of that $60)
  • Recommendations from deputy CFO:
    • Have per diem contracts with ACOs negotiated at a percentage rate, not fixed $ amount
    • Send claims on a daily basis, not monthly
    • Make sure practice management system is sending automatic claims, hire detail-oriented staff if a lot of front end work needed, good idea to have a certified coder on staff
    • Manage payer mix
    • Each payer coding preferences differ, ensure coding doesn’t look like an inpatient visit

Stacy Kirkpatrick House

A first-floor residential setting embedded with separately run supportive housing units, with space for case management, recreation room, and outdoor areas across the street from a large park.

  • Former nursing home site; current building shared with City’s supportive housing, but they are managed independently
  • $1.5 million annual budget operating at a loss due to higher proportion of undocumented patients in the mix (as an independent site but ultimately beneficial, so other robustly funded areas of the Boston HCH make up for this)
  • 20-bed for low-risk care; 2-4 beds/room
  • 2 nurses/day, 14-hour/day 7 days/week nursing 
  • Case management staff 24/7, trained in CPR and vitals for overnight coverage
  • Once-a-week visit by PCP (12 hrs/week total provider time)
  • 60 or 40*-day average LOS, has been up to a year
  • Sex-mix similar to acute care site

Boston Healthcare for the Homeless

  • 30 outpatient clinics in shelters
  • Street Team with internist, nurse practitioner, psychiatrists, case managers
  • HCH-employed nurses embedded at most hospitals

Other Notes

  • They do code for homelessness (Z59 code)—increases risk score and reimbursement rate by ACO
  • Medicare subchapter 5 stipulates what you can bill in regards to split billing
  • David emphasized that every respite is unique, and that our model will be more like Stacey Kirkpatrick—getting to Barbara McInnis capacity would take years, but also would caution against that being a focus—David himself says that’s more like a small hospital and it doesn’t focus on linking folks to long-term solutions
  • The National Healthcare for the Homeless has a directory of respites and a number of resources accessible here: https://nhchc.org/clinical-practice/medical-respite-care/medical-respite-directory/
  • Those resources include Standards for Medical Respites & a Respite Toolkit
  • David says there will be a training in the next year specifically for folks opening respites and advises someone who is in the planning/operations attend—no date yet but will be offered by NHCHC. Sara is on their mailing list. If anyone else wants to be, visit: https://nhchc.org/who-we-are/get-involved/

*Sara and Sharmistha have conflicting numbers on this

ADDENDUM D: MEDICAL RESPITE ADVOCACY PLAN FOR NYC

MEDICAL RESPITE BED ADVOCACY PLAN

There is no question that we need medical respite beds in New York City. Many of our service providers will attest to this. People suffering homelessness are deprived of complete recovery alternatives after leaving an emergency room. People are mostly cared for by family or visiting nurses after returning home to ensure successful recovery. People who are homeless do hot have access to aftercare, and hospitals are reluctant to house people beyond their needed emergency care. As one Mount Sinai doctor said, “We’re not a Holiday Inn.” 

A medical respite bed facility can be a pipeline from the hospitals to health, medical, social, and other services, which can lead to housing opportunities. 

This four-step plan is to encourage the development of medical respite beds in NYC. This is a plan in progress, not without flexibility, and is open for suggestions.

Step #1 (Began November 2019) Mission:

Describes our mission (the encouragement of medical respite beds) and suggests the following pathways to complete that mission:

  • Encourage medical respite bed funding through the city budget
  • Ask the city to fund a pilot project to study the financial and clinical outcomes
  • Encourage the network of providers to develop medical respite beds

A press release describing the committees’ intentions, emphasizing the forthcoming presentations, and encouraging attendance could be prudent.

Step #2 (March 2020) Information Gathering:

This step requires a tremendous amount of information gathering affirming the necessity, sustainability, and capital to develop a respite bed facility. Fortunately there are successful examples and developers who are willing to guide this endeavor. The Information Gathering should include, but not be limited to:  

  • Statistics outlining success in other states
  • Costs difference between emergency care and respite bed facilities
  • Developmental and operational cost analysis
    • Daniel Muwamba, Deputy Chief Financial Officer, Boston Health Care for the Homeless Program is already working on financial details of the Barbara McInnes House and Stacey KirkPatrick facilities
  • Short documentaries and testimonials speaking to medical respite needs
  • Video and PowerPoint presentations affirming the medical respite beds necessity and benefits:
    • Andy Coyle, M.D., Assistant Professor of Medicine and Medical Education, Associate Program Director for Ambulatory Care, Internal Medicine Residency Program, Icahn School of Medicine at Mount Sinai, has shared a great deal of knowledge during a conference call and with his PowerPoint presentation, using data from March 2019, and he is willing to further support our endeavors: 
      • I can pull updated data if there is an opportunity to speak to a group…I can also share more of our outcomes data for the respite as we have it.
    • Comunilife’s Rosa Gil, DSW, President and CEO, has contracts with Monte, Bronx Lab and a couple Medicaid Managed Care plans for medical respite bed care
    • David Munson, Barbara McInnes House, has shared details of his operation and as with Dr. Coyle, is willing to support our endeavors
    • BronxWorks, is partnering with One City Respite Program, to lower the cost of emergency room use, to provide longer care for persons without a residence, and to enable a pathway to better health and housing stability (an interim step towards medical respite beds?)
    • Insurance Companies: Health First, United Healthcare, MetroPlus, AMIDACARE
    • DHS, Outreach services, and NYDIS: How can medical respite beds benefit?

The video presentations should educate, speak to the need, and empower others to advocate for medical respite facilities. 

Step #3 (July, August 2020) Administrative, Proposal Development, and Marketing: 

This step collates the work from Steps 1 & 2, fills in the gaps, and tailors it to the needs of client and state for a finalized proposal to encourage the development of medical respite beds. This step serves the final presentation and marketing needs, and also encourages support and participation. 

Step #4 (September, October 2020) Advocating for Development:

This is the culmination of discussions, meetings, research, discoveries, proposals and presentations to gather the support from nonprofits, city agencies, governing bodies, medical institutions, and humanitarian developers to realize the building of medical respite beds.

ADDENDUM E: COMMUNILIFE BROCHURE

About Comunilife 

Founded in 1989, Comunilife is a not-for-profit health and human services agency providing comprehensive mental health, social services and housing. Our mission is to provide vulnerable communities with housing and culturally sensitive support services. 

Services are provided to homeless persons living with mental illness, addictive disorders and HIV/AIDS to enable them to live independently in their community. In addition, we provide affordable housing for persons with low income. 

Comunilife programs employ our Multicultural Relational Approach for Diverse PopulationsTM which emphasizes respect for people’s cultural differences while mobilizing an individual’s strengths and resources of the community. Comunilife currently serves some 3,500 New York City residents throughout the Bronx, Queens, Brooklyn, and Manhattan. 

To make a tax deductible donation please visit www.comunilife.org/donation/. Donations may also be made by mail. For more information contact the development office at (212) 219-1618 ext. 6166 or ikaplan@comunilife.org 

Board of Directors: Raquel Ayala, Chairperson Veronica Kelleher, Vice Chairperson Jason P. Torres, Treasurer Frances Pandolfi, Secretary Carolina Buzzetti Gary Calnek Ruben Cardona Amarylis Cortijo, MD Steve Dyott Hazelien Featherstone James Geraghty Pamela J. Maraldo, PhD Carlos R. Piñeiro, Esq Miguel Sanchez, MD Ann Sullivan Marlene Zurack [NEED COMMAS INBETWEEN NAMES]

Rosa M. Gil, DSW Founder, President and CEO 

For more information or to discuss medical respite care services contracts, contact: Rosa Cifre, LCSW Chief Program Officer Comunilife, Inc. 462 Seventh Avenue New York, NY 10018 T: (718) 617-1978 info@comunilife.org www.comunilife.org 

Comunilife healthy living in community  SOCIAL/MEDICAL RESPITE CARE 8/2015 

Admission criteria: Social/medical respite care programs will serve persons who: 

  • Lack suitable housing 
  • Have acute or post-acute medical illness which requires short-term resolution and/or care 
  • Need an environment in which to prepare for, or recover from, medical procedures such as surgery, chemotherapy, radiation, endoscopy, etc. 
  • Are independent in activities of daily living (ADL) with the ability to dress, bathe, transfer and ambulate independently, or with mechanical assistance such as a wheelchair, crutches or cane 
  • Are psychiatrically stable enough to accept and receive care and not interrupt the care of others 
  • Are sick enough to need more than an emergency shelter bed for the night 
  • Are not sick enough to require hospital level care or other medical care (nursing home, psychiatric in-patient care, rehabilitation hospital) 
  • Have a condition with an identifiable end point of care for discharge.
    (Patients requiring IV hydration will be assessed on an individual basis.) 

What is social/medical respite care? 

Social/medical respite care is acute and post-acute medical care for persons who are too ill or frail to recover from a physical illness or injury but who are not ill enough to be hospitalized. These individuals may be homeless, or may simply not have a family member or friend to care for them. 

Unlike “respite” for caregivers, “social/ medical respite” is short-term residential care that allows individuals the opportunity to rest and recover in a safe environment while accessing medical care and other supportive services. For homeless patients, staff help secure permanent housing prior to discharge from the program. Challenges such as obtaining food, clothing and shelter, or achieving or maintaining sobriety can compromise adherence to medications, physician instructions and follow-up appointments, thus increasing the probability of future hospitalizations. 

Social/medical respite care closes the gap between acute medical services provided in hospitals and the need for appropriate housing. It is an essential component of the continuum of health care services for the elderly and the homeless. 

Our medical respite care is offered in existing transitional housing. 

Why is social/medical respite care needed? 

It is not uncommon for persons who live alone and have been hospitalized to be temporarily unable to care for themselves following hospital discharge. In the absence of an available caregiver, social/medical respite care can avoid costly and traumatizing external and unnecessary hospitalization. 

For the particularly at-risk homeless population, living on the streets exacerbates health problems, complicates treatment, and disrupts the continuity of care. These people tend to have high rates of physical and mental illness, increased mortality, and frequent hospitalizations. 

Research shows that patients who participate in social/medical respite programs are 50 percent less likely to be readmitted to a hospital at three months and twelve months post-hospital discharge. 

Social/medical respite care generates significant savings for hospitals and communities, avoiding costly discharge delays as well as reducing hospital readmissions. 

 ADDENDUM F: NON-MEDICAL RESPITE POLICY RECOMMENDATION

Respite Bed Suggested Policy

DRAFT 11/1/19 Cassie Dessalines with Reggie Miller’s added comments

Respite Bed Suggested Policy

Definition:

Drop-In Center– A Drop-In Center is a location in NYC where anyone can walk in and receive emergency shelter services. This may include a meal, shower, laundry and basic referral and assessment. If found to be chronically street homeless an individual could be placed on case load where they could receive case management services to achieve an end goal of permanent housing. Drop-In Centers have no beds and clients sleep in chairs.

Chronically Street Homeless– To meet eligibility for caseload a person must be able to prove they have lived on the street for 9+ months. This is often proved through a street outreach team (1 per borough) or through a social service agency that has engaged this person on the street.

Respite Beds– (aka Congregation Beds) Community agencies, including churches, community centers, synagogues, etc. will partner with Drop-In centers and allow clients to come and sleep in their facilities overnight. The social service agency will provide supplies such as beds, linens, care kits etc. and the community agency will provide the space and a volunteer to supervise clients overnight.   

Who Can Utilize Respite Bed Sites:

In order to meet eligibility criteria to utilize a respite bed, clients will need to hit a certain level of functioning. Administrative staff will be heavily involved in who will be eligible to attend. This eligibility will be determined by the following:

  • Clients will be on caseload. If a client is on an extended temp stay and is vulnerable, they may be sent, however, this decision will be on a case-by-case basis and will need approval from either PD or Clinical Coordinator.
  • Clients will need to be able to tolerate being in a different, less supervised, setting than the Living Room. They will need to be calm and peaceful while there.
    • Reggie: Please elaborate. Historically this meant that guests were not under the influence of alcohol or drugs, did not pose a threat to themselves or others, and if they had active mental health or substance abuse issues they were stabilized on whatever medications or other treatment plans were necessary. They also needed to be in relatively good health (not obviously unwell and/or infectious) and demonstrate relatively good hygienic practices. Is this no longer the case? Or is this an attempt to shift this (excluding the ADL’s which I know and understand there is a desire to shift)?
    • Cassie: This is an attempt to state that even though a client may have untreated mental health issues they should not be excluded as long as they can reasonably tolerate the environment.  
  • Clients need to be sober. Clients who need to smoke will be given an area to do so, however, abstinence from drugs or alcohol will be expected while staying at the respite site.
    • Reggie: This not always possible to do based on where within the building the shelter space is located, and maintain the integrity of the shelter space, especially after lights out.
    • Cassie: Understood. Just wanted to highlight that when clients are able to smoke they are more likely to attend.
    • Reggie: At the risk of being pedantic about semantics, this is a requirement. Granted, some volunteers are more flexible than others about whether a guest can stay if they arrive under the influence, I’m not aware of any who will look the other way at active use on site.
    • Cassie: Agreed

**It is my suggestion that ADL requirements be lifted from the policy already in place. Chronically street homeless individuals often struggle with ADL’s. Poor ADL’s do not pose any danger to other individuals, therefore should not preclude someone from accessing a bed.

  • Reggie: While I agree with the sentiment, this is going to be a hard sell for a number of reasons. Someone with poor ADL’s do not pose a danger in the same fashion as someone with active untreated psychosis, for example, but there are health and sanitation concerns and more often than not shelter spaces are shared spaces. This is certainly a topic worth further discussion, but expect a great deal of pushback.  
  • Cassie: Push back is fine, however, we need to be clear that the majority of street clients cannot be expected to have good ADLs.

Requirements for Respite Sites

  • Respite site will provide the agency with a space for clients to sleep.  
  • Provide a contact or liaison to discuss day-to-day needs or issues.  
    • Reggie: Drop-Ins should have information for an overall point of contact for each shelter. I know this can create a game of telephone when it’s necessary to reach the volunteer on duty on a given evening, but presently that is the most stable/reliable way to reach someone and to reach someone who has a reasonable idea of what’s going on. Not all shelter spaces have phones or reliable phone service. The conversation about a burner phone is one worth continuing, though we’d have to work out who and how it was being paid for.
    • Cassie: We have gotten approval for the Trac phone and plan to implement soon.
  • Provide a number to reach the volunteer with issues, i.e. lateness/cancellation.
    • Reggie: See above. Shelters should also have contact information for overnight Drop-In Center staff to reach out to with concerns.
    • Cassie: Trac phone will address this as well.
  • Volunteers will be present for the entirety of the clients’ stay.
    • Reggie: This is, or at least should be, standard procedure. I’m not aware of any circumstances in which at least one volunteer is not on premises for the duration of the guests stay.
    • Cassie: Is standard. Just included as a part of a complete policy.
  • Volunteers will attend an on-boarding session with the social service agency that is sending the clients.
    • Reggie: Agency Evening Shift Supervisors should also attend an orientation session at each shelter site.
    • Cassie: Agreed. Or perhaps a respite coordinator is available.
  • Volunteers will attend a Mental Health First Aid Training, Narcan Overdose Prevention, and Basic First Aid.
    • Reggie: NYDIS is working on expanding the scope of trainings available to shelter volunteers. This will be among the courses on offer.
    • Cassie: Great!
  • I would suggest a regular meeting with each church bed (monthly/bimonthly) to discuss any issues or concerns.  
    • Reggie: This is on my list of things to do.
    • Cassie: Great!
  • I would suggest that each site serve some sort of food/snack as able. (Many do this already)
    • Reggie: Generally speaking, those who have the facilities and the financial ability to do so, do so. This is also something on my list of things to figure out how to make happen.
    • Cassie: Understood
  • I would suggest that each site provide a space where clients could smoke. This could even be a time where the volunteer brings clients outside to smoke at a designated time. (Some already do this)
    • Reggie: As mentioned above, this is not always physically possible. I don’t know that this happens anymore, but this also used to be an area that created friction between host sites and their neighbors. To avoid problems with their neighbors, some nixed allowing guests to smoke period.
    • Cassie: Understood.

Requirements for Drop-In Center

  • Provide all necessary supplies including but not limited to cots, sheets, pillows, care kits, any additional personal supplies (adult diapers, feminine hygiene products)
  • Provide any and all trainings and materials for volunteers as needed.
    • Reggie: This should be a NYDIS task. We are happy to coordinate and work with Drop-In staff on trainings, but these should be standardized across all ESN sites.
    • Cassie: Great.  
  • Provide a 24 hour line for volunteers to call with issues.
    • Reggie: Complete with a name(s) to ask for.
    • Cassie: Agreed. Trac phone can be programmed with all appropriate contacts.
  • Provide transportation to and from site locations for clients at predetermined times. There should be a 15-minute grace period both for pick-ups and drop-offs.  
  • Provide line staff with a list of eligible clients that is updated daily. Line staff will conduct a superficial assessment of clients before they get on the van.
    • Reggie: Please define “superficial”.
    • Cassie: Meant to highlight that we are simply doing an informal assessment based on our best judgment.  This is not a perfect science and it must be understood that clients conditions may changed based on numerous variables.
  • If medication is needed and a client is on MMT, client will be packed out prior to leaving and will take needed doses independently at the site (**of note, this may include controlled substances such as Suboxone. This will be monitored and prescribed by an onsite doctor.)
    • Reggie: Volunteers will need to be apprised of this, without violating guests’ privacy. Volunteers don’t need to know what (exactly) or why a guest is taking something, but they will need to know that the guest will be taking something, what it looks like, how much, how often, and what effect they will have on the guest after they’ve been taken.
    • Cassie: Agreed.
  • Attend all conference meetings and respond to all requests within a reasonable amount of time.  
    • Reggie: Please define “reasonable amount of time”.
    • Cassie: Communication response should be within 24 hours. We need to be clear that orders can sometimes take an extraordinarily long time. 

ADDENDUM G: JOSEPHINE ISHMON’S EMAIL

The below email requests updates regarding laundry machines, daycare needs to be added to the agenda, and more…

John, please add day care to the list.

Yesterday, I met briefly with Acacia (who oversees 7 midtown shelters) and

they need more resources, specifically day care and laundry to handle the

influx of homeless families from FEMA. Mothers cannot work without daycare

for their children and they are having problems finding daycare centers

that will take DHS vouchers. I asked them to try Hudson Guild and Polly

Dodge Early Learning Center.

If anyone knows of other daycare centers in the midtown area, please advise.

They also asked for more laundry vouchers and I gave them what I could but

need to keep a good portion in reserve for the start of the school year.

Matt, have we gotten a meeting with NYCHA on laundry machines for the

smaller space?

Best,

Josephine