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Fort Worth Community Collaboration for Chronically Homeless People Saves $443,000 in 2016

New program significantly reduces emergency room visits by chronically homeless in Fort Worth



The Salvation Army

Pat Patey


JPS Health Network

J.R. Labbe


FORT WORTH (June 26, 2017) – A collaboration between The Salvation Army, JPS Health Network and Tarrant County is reducing the incidence of homeless people using emergency rooms and ambulance service to access basic healthcare services. In 2016, this program saved approximately $443,000 while also working to improve the health of medically vulnerable individuals experiencing homelessness.

This new program grew out of a 2015 meeting between representatives from JPS, the Tarrant County Community Development and Housing Department, and The Salvation Army’s Mabee Center in Fort Worth to discuss service gaps for the homeless in their community and ways to help plug those gaps. A couple of key facts surfaced in the meeting: 1) Medically vulnerable homeless people make frequent and repeated calls to 9-1-1 for an ambulance or go directly to the emergency room for non-emergency, basic healthcare needs, and 2) Such high utilizers of emergency care create a tremendous cost burden for the local healthcare system, usually without improving the day-to-day, ongoing health needs of those homeless patients.

In fact, just 24 homeless individuals accounted for more than $900,000 in behavioral and medical health care at JPS in 2015. One homeless person visited the JPS emergency room 73 times in a12-month period. And the potential exists for even greater demand on the local healthcare system from the 217 people identified in 2016 as chronically homeless by the Tarrant County Homeless Coalition.

These representatives from JPS, Tarrant County, and The Salvation Army believed they were onto something important, and they wanted to work together to find a solution. The result was the launch in November 2015 of “Pathways to Housing,” where apartments are “prescribed” as part of a comprehensive care plan to improve the health of medically vulnerable individuals experiencing homelessness.

Living on the streets is a major contributor to ill health. The “Pathways” organizers recognized that the traditional approach of trying to meet the healthcare needs of chronically homeless men and women first before placing them into permanent housing was not working. The organizers agreed that it would be critical to first stabilize housing needs before attempting to stabilize ongoing healthcare issues for these frequent visitors to the JPS ER.

A fourth partner, Amerigroup, also joined the Pathways initiative and has been key to its success. Amerigroup is the largest healthcare provider of Medicaid services in Tarrant County. The agency works with people who need help obtaining healthcare, including homeless people, individuals with mental health and substance use needs, people with intellectual and developmental disabilities, and citizens who are elderly and sick.

Pathways to Housing has shown success in implementing permanent supportive housing as an intervention for healthcare within the first year. Fourteen former, chronically homeless individuals now have permanent supportive housing, long-term comprehensive case management, and access to ongoing healthcare. Each person who was housed in year one of the program has shown a decrease in emergency department utilization at JPS, resulting in significant cost savings.

Emergency room use decreased by 21.74 percent. Urgent Care saw a 42.54 percent decrease, while the JPS Behavioral Health Emergency Room saw a 58.15 percent decrease. As a result, JPS realized savings that totaled $417,938 in 2016. This number includes $214,184 in Emergency Room visit charges, $154,620 in Behavioral Health Evaluation Unit charges and $49,134 in Urgent Care visit charges. Early numbers indicated that Amerigroup saw a savings of more than $25,000 in 2016 from those enrolled in the Pathways to Housing program.

Pathways to Housing plans to double in size in 2017, moving to at least 30 housing units. The Salvation Army will be adding another full-time case manager to assist as more clients are enlisted and moved into their own apartments. It is projected that 2017 will yield savings of $778,855.

Here’s how Pathways works: Potential participants are initially identified by Amerigroup as high utilizers of emergency services. Amerigroup sends a list of these individuals directly to JPS, which matches these individuals to their records designating them as “possibly homeless.” A new list is created and forwarded to The Salvation Army to begin outreach and the process of establishing housing eligibility through the Coordinated Assessment process that prioritizes individuals based on their Vulnerability Index, operated by Tarrant County Homeless Coalition.

The Salvation Army then makes initial contact with potential participants to explain the program and discuss housing options. A Salvation Army case manager provides each person with the direction and guidance needed to create an individualized care plan and to achieve their personal goals, including assisting them in meeting the obligations of being an apartment tenant. The case manager works with local apartment managers to find apartments for program participants, with rents paid by a multi-year grant secured specifically for Pathways to Housing.

The Salvation Army case manager makes multiple contacts with each participant on a weekly basis both before and after they are placed into housing. Assistance provided by the case manager may include help with landlord issues, providing basic needs such as food and hygiene items, and making referrals to community agencies and resources.

After the individuals move into their apartments, The JPS Care Connections Team – which has traditionally provided healthcare on the streets of Fort Worth as a bridge between homeless individuals and the hospital – provides healthcare services within the participants’ homes. The JPS clinical case manager is responsible for initial assessments that measure each participant’s current health condition along with learning about their health history. Assessments include a patient health questionnaire, a cognitive screening, an early childhood trauma screening and a post-traumatic stress disorder (PTSD) survey. The JPS Care Connections Team also works closely with each individual to establish a healthy home in the community where they have obtained housing. Ongoing services include health assessments, medical referrals and help setting medical appointments.

Amerigroup then provides behavioral health case management via phone to individuals enrolled in Medicaid through Amerigroup. The behavioral health case manager answers questions regarding eligible services as well as makes needed referrals in the community. In year one of the program, the behavioral health case manager made 219 calls.

One example of Pathways’ success is James, 58, a Mississippi native who has lived in Fort Worth for 20 years, many of them without shelter since losing his job metal-plating for a defense contractor. Worsening chronic obstructive pulmonary disease (COPD) and other health problems caused him to be admitted to the ER at JPS more than 50 times in 12 months, making him a candidate for Pathways to Housing. James now lives in a small apartment near bus routes he can use to keep medical appointments, rather than requiring weekly home visits by practitioners from the JPS Care Connections program.

Year one of this project has further demonstrated that addressing basic socio-economic factors such as housing can positively impact a person’s health. Stable housing provides an opportunity for individuals to get away from continually living in crisis conditions and patterns of crisis thinking and behaviors. It also allows them to have a safe environment to learn and practice healthy choices and to access appropriate health interventions, coaching and education. Pathways to Housing plans to provide this intervention to more individuals, lowering costs and reducing the number of chronically homeless individuals living in Tarrant County.

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